Resident Burned After Unauthorized Use of Space Heater
Penalty
Summary
A deficiency occurred when a portable space heater was used in a resident's room, resulting in a burn injury. The resident, who had a history of traumatic subarachnoid hemorrhage, paraplegia, and autonomic dysreflexia, requested the use of a heater brought by his family due to his tendency to feel cold and sweat excessively. Despite being aware that heaters were not permitted in the facility due to fire and burn risks, an LPN set up the heater approximately three feet from the resident at his request. The resident, who was cognitively intact but had impaired sensation due to his spinal injury, was later found with redness and blisters on his right elbow by another nurse and CNA during their rounds. The resident was unaware of the injury due to his lack of sensation in the affected area. Medical documentation confirmed a diagnosis of a second-degree burn on the resident's right elbow, which subsequently became infected with Enterococcus Faecalis and MRSA, requiring multiple courses of antibiotics. Facility policy review indicated that space heaters were prohibited due to safety concerns, and staff interviews confirmed that the heater was used against established protocols. The incident was identified as a failure to maintain a safe, hazard-free environment, as required by facility policy and regulatory standards.