Failure to Immediately Notify Family, Physician, and IDPH After Resident Burn Incident
Penalty
Summary
The facility failed to immediately notify a resident's family, physician, and the Illinois Department of Public Health (IDPH) following an incident in which the resident sustained burns from spilling hot chocolate on herself. On the day of the incident, the resident was observed with a red area on her left hip after the spill, but there was no documentation that the family or physician were notified at that time. The following day, blistering was noted on the resident's left waist and upper thigh, at which point the Director of Nursing contacted the resident's primary care physician and power of attorney. Both the physician and the family confirmed they were not notified until the day after the incident. The facility's policies require immediate notification of serious incidents to the resident's physician, family, and the IDPH, with specific procedures for reporting and documentation. Despite these requirements, the incident was not reported to the IDPH, and the notifications to the family and physician were delayed until after the resident's condition worsened. The staff involved stated that they believed notifications had been made, but there was no documentation to support this, and the responsible parties confirmed they were unaware of the incident until the following day.