Failure to Follow Electrical Equipment Safety Policy Leads to Resident Injury
Penalty
Summary
The facility failed to follow its own policies regarding the inspection and safe use of new electrical equipment, resulting in an avoidable accident involving a resident. The resident purchased two electronic hand warmers for personal use when going outside. According to the facility's policy, all new electrical equipment must be inspected by the Environmental Services department, and if deemed unsafe, should not be used. The Director of Plant Operations recalled being shown the devices by two CNAs and determined that the devices became too hot and required a protective barrier between the device and the skin, as stated in the manufacturer's instructions. However, this assessment was not documented, and neither the resident nor the Director of Nursing was informed. The devices were not formally approved or labeled as inspected, as required by policy. The deficiency was further compounded when a staff member, whose identity was not disclosed, placed the warmer directly on the resident's left hand without a protective barrier, resulting in two blisters measuring 2.8 x 1 cm and 2 x 1.4 cm. The blisters were discovered by a CNA and subsequently assessed by the DON, who was previously unaware of the injury. The resident reported that he typically used a layer of clothing as a barrier but that this protocol was not followed on the occasion that led to the injury. The lack of adherence to the facility's policy and failure to communicate findings regarding the safety of the devices directly contributed to the resident's injury.
Plan Of Correction
Education prepared for staff by LTC DON regarding electrical equipment and resident safety, including the Arrival of New Electrical equipment policy for review. All staff are to review and sign acknowledgement. The policy MAIN-043 Arrival of New Electrical Equipment will be added to the admission packet. The DON will inform new residents and their responsible parties of the policy and they will sign an acknowledgement of understanding. Director of Plant Operations will amend her existing QA Patient Care Equipment Inspections to include Personal Equipment. The Director of Plant Operations will monitor all equipment to ensure the equipment has been inspected and approved for use during the Safety Hazard/Injury Prevention Inspection that is conducted at least monthly.