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F0684
D

Failure to Provide Timely Treatment After Resident Burn Injury from Electrical Outlet

Fort Worth, Texas Survey Completed on 04-15-2025

Penalty

Fine: $21,64527 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident sustained burns and blisters to her fingers after coming into contact with a malfunctioning electrical outlet in her room. The incident took place in the early morning hours, when the resident attempted to plug in her charger and was shocked, resulting in visible injuries including black charred marks and white blisters on her fingers and thumb. The resident reported pain, numbness, and anxiety following the event, and took photographs of her injuries and the damaged outlet. Multiple other residents and staff later confirmed seeing the injuries and the damaged outlet, with one resident describing the affected areas as raw, red, and pink, and another resident assisting in documenting the injuries with photographs. Despite the resident's report of being shocked and showing her injuries to staff, including a nurse and a social worker, the initial nursing assessment documented no visible injuries and no complaints of pain at the time. The nurse prioritized moving the resident to a different room for safety but did not provide or document any treatment for the burns or blisters. The incident was not entered into the facility's incident/accident log, and no incident report was completed for the event. Interviews with staff, including the DON, ADON, and Administrator, revealed that follow-up assessments were not conducted, as the initial assessment was believed to show no injury, and staff were not made aware of the resident's subsequent complaints or visible injuries. The facility failed to provide treatment and care in accordance with professional standards of practice and the resident's care plan, as the resident did not receive appropriate assessment or treatment for her injuries following the electrical incident. The lack of documentation, failure to complete an incident report, and absence of follow-up assessments contributed to a delay in treatment for the resident's burns. The event was corroborated by photographic evidence and multiple witness statements, but the facility did not recognize or address the resident's injuries in a timely manner.

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