Failure to Report Resident Burn Incident as Required
Penalty
Summary
The facility failed to ensure that all alleged violations were thoroughly investigated and properly reported to the New York State Department of Health as required. A resident with a history of left-sided paralysis following a stroke, who was cognitively intact and generally independent with activities of daily living, sustained superficial burns with blisters to the lower abdomen and upper inner thigh after accidentally spilling hot water while preparing food. The incident was witnessed and documented by multiple staff members, and the resident consistently reported the injury as accidental, occurring while straining hot water from food prepared in the microwave. Facility policy required reporting and investigating any accident or incident involving a resident, and state guidelines specifically mandated reporting burns to the body surface. Despite this, the incident was not reported to the Department of Health. The incident/accident report and staff statements confirmed the sequence of events, including the resident's use of the microwave, the assistance provided by staff, and the resident's subsequent self-inflicted burn. The resident was assessed by nursing staff and a nurse practitioner, with documentation indicating the burns were superficial, resolving, and not causing pain or infection. Interviews with staff revealed that the Director of Nursing was informed of the incident but did not report it to the state authorities, citing a lack of awareness that such burns were reportable. The facility determined internally that the incident was self-inflicted and not reportable, contrary to state requirements. This failure to report the incident as mandated constituted the deficiency identified during the survey.