Failure to Timely Notify Physician and Representative After Resident Burn Injury
Penalty
Summary
Facility staff failed to notify the physician and resident representative in a timely manner after a resident spilled hot coffee on their right leg, resulting in a significant burn injury. The initial documentation by an LPN noted a red, blotchy area with no blistering and indicated continued monitoring, but did not include notification to the physician or the resident's responsible party. Two days later, staff documented the presence of fluid-filled blisters on the resident's right inner knee and thigh, at which point the physician and resident representative were notified. The facility did not have a policy specifying when to notify the physician or resident representative of an injury or change in condition. Interviews revealed that both the administrator and the ADON did not expect staff to notify the physician or resident representative for what they considered a minor injury without significant pain, based on the initial assessment. However, the resident's physician stated that notification should have occurred shortly after the injury or within 24 hours. The LPN involved acknowledged that notification should have been made but was not due to being busy and forgetting. The resident was assessed as having moderate cognitive impairment and was independent with eating, bed mobility, and transfers at the time of the incident.