Resident Sustains Burns Due to Improper Heat Pack Application
Penalty
Summary
A resident with kidney disease, who was cognitively intact and required partial assistance with upper body dressing, was admitted without any skin impairment. The resident had standing orders for a heat pack, but these orders were not transcribed onto the Treatment Administration Record (TAR). On one occasion, a CNA provided the resident with an insta-hot heat pack without first communicating with a nurse or ensuring a barrier was placed between the heat pack and the resident's skin. The CNA handed the heat pack directly to the resident, who then applied it herself/himself. Staff did not monitor or ensure the timely removal of the heat pack. As a result, the resident kept the heat pack on for an unknown period, leading to the development of superficial blisters and redness on the shoulder and underarm. The next morning, the resident reported itching, and upon assessment, clear and uncapped blisters were observed, with some skin sloughing noted. The incident occurred due to a lack of staff supervision, failure to follow proper procedures for heat pack application, and absence of documentation and communication regarding the intervention.