Failure to Monitor Resident During Heat Therapy Results in Burn Injury
Penalty
Summary
The facility failed to ensure proper monitoring and assessment of a resident during a hot pack treatment, resulting in actual harm. The incident involved a resident who sustained a burn on the right shoulder after receiving heat therapy. The facility's policy required that residents be checked every 5-10 minutes during such treatments, and that the area be inspected for any unusual signs after the treatment. However, these procedures were not adequately followed, leading to the resident's injury. The resident, who had a medical history including anemia, hyperlipidemia, hypertension, and diabetes, requested heat therapy for shoulder pain during a physical therapy session. The Physical Therapy Assistant (PTA) applied the hot pack without proper authorization or documentation, and failed to monitor the resident's skin condition during and after the treatment. The resident later reported irritation and a burn-like area was discovered on the shoulder, which was confirmed by a licensed nurse and a wound nurse. The incident was further compounded by the fact that the hot pack treatment was not part of the resident's authorized plan of care, and the PTA did not consult with a physical therapist before administering the treatment. Additionally, there was no documentation of the treatment duration or the condition of the resident's skin, which was a requirement of the therapy department. This lack of adherence to established protocols and failure to monitor the resident's condition led to the resident sustaining a burn injury.
Plan Of Correction
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual. a. The resident (R 302) wound was resolved and discharged to home instructed to apply vaseline to keep skin moist and tight. The Contracted employee of Select Rehabilitation Co (E9) was educated on 11/14/24 for not following the plan of care for treatment, as a result his employment was Terminated at St Joseph Villa. Date: Deficient Practice was resolved on 11/4/24. 2. Indicate how the facility will act to protect residents in similar situations. a. All residents were reviewed for Hot Pack treatments to ensure any contraindications, precautions, adequate supervision and monitoring for signs of skin irritation and burning, there were no other residents receiving hot packs. The use of Hot Packs were discontinued for all residents and the use of the Hydrocollator Mobile Heating Unit was discontinued on 11/14/24. Date: Deficient practice was resolved on 11/14/24. 3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur. a. The clinical staff coordinator and director of therapy provided formal education to the nurses and therapy staff for Hot Pack treatments to ensure any contraindications, precautions, adequate supervision and monitoring for signs of skin irritation and burning on 11/14/24. Date: Deficient Practice was resolved on 11/14/24. 4. Indicate how the corrective action will be monitored to ensure that the deficient practice will not recur: a. An audit tool is in place for all residents with orders for Hot pack treatments and reviewed by the Nurse Coordinator for any contraindications and precautions prior to treatment and to ensure adequate supervision and signs of skin irritation. The audit will be reviewed weekly x 4 and then monthly, results were reviewed and discussed at Quarterly QAPI meeting. Date: Deficient Practice was resolved 11/14/24. 5. Dates of when the corrective action will be completed: a. The facility completed this plan of correction 11/14/2024.