Resident Sustains Full-Thickness Burn Due to Improper Foot Soak and Inadequate Supervision
Penalty
Summary
A resident with a history of diabetes mellitus, neuropathy, and a diabetic foot ulcer required partial to moderate staff assistance for lower body dressing and footwear. The resident's care plan included an intervention to avoid exposure to extreme heat or cold. During a scheduled wound care session, an LPN prepared a basin of water for the resident to soak his foot, intending to clean the area before treatment. The LPN checked the water temperature by hand while filling the basin but did not verify the temperature after the basin was filled. The resident initially expressed that the water felt hot and removed his foot, but the LPN reassured him and left the room to retrieve supplies, instructing him to wait. While the LPN was out of the room for approximately five minutes, the resident placed his foot back into the basin. Upon the LPN's return, a blister had developed on the top of the resident's left foot. The resident, who experienced frequent numbness in his feet due to neuropathy, did not realize the water remained too hot. Subsequent nursing assessments documented the development of blisters, sloughing, copious drainage, and significant pain. The resident later described the pain as excruciating, and the wound was observed to be a third-degree burn with yellow slough, redness, and matted toes. The incident resulted in the resident being transferred to an acute care burn unit, where he was diagnosed with a full-thickness scald burn to the left foot and underwent two surgical procedures for debridement and skin grafting. Interviews with facility staff confirmed that soaking the resident's foot was not part of the wound care orders and that the LPN should not have left the resident unattended with the basin of water. The lack of proper supervision and failure to ensure safe water temperature directly led to the resident sustaining a serious burn injury.