Failure to Provide Timely Burn Treatment and Inadequate Care Planning
Penalty
Summary
Facility staff failed to provide timely treatment to a resident who sustained a burn injury to the right thigh after spilling hot coffee. The incident was documented by an LPN, who noted redness but no blistering and decided to monitor the area without administering any treatment or notifying the physician. No treatment interventions were documented until two days later, when staff observed fluid-filled blisters and applied Silvadene cream after notifying the physician. The care plan did not include interventions for providing or monitoring hot liquids, and there was no documentation of assessment regarding the resident's consumption of hot liquids in the electronic medical record. The facility did not have a policy addressing changes in a resident's condition following a burn injury. Interviews revealed that staff did not initiate immediate treatment, such as applying a cool compress or contacting the physician, as would have been expected. The resident, who had moderate cognitive impairment and was independent with eating and mobility, was not provided with timely care or documentation following the burn, and staff failed to update the care plan with appropriate interventions related to hot liquid safety.