Severe Burn Injury Due to Prohibited Space Heater Use During HVAC Failure
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards when the HVAC system malfunctioned in one area, causing room temperatures to drop below the required range. In response, portable space heaters, which are prohibited in resident rooms, were placed in four rooms. This action directly led to a serious incident where a resident with lower extremity paralysis and decreased sensation, due to spinal cord compression and other comorbidities such as diabetes, sustained a full thickness burn on the left leg and foot after being positioned too close to a space heater. The burn was severe, resulting in blistering, skin breakdown, and subsequent infection with faecalis and E. faecium, requiring hospitalization and ongoing outpatient burn care. Multiple staff interviews and documentation confirmed that the space heaters were present in several rooms during the period of heating system failure. Staff members reported that the heaters became hot to the touch and could cause burns. There was confusion among staff regarding the origin and authorization of the space heaters, with some stating that maintenance or administration directed their placement, while others denied knowledge of their presence. The affected resident was observed by staff and family to be sitting within inches of the heater, and due to his paraplegia, was unable to sense the danger or move away, resulting in significant injury. The facility's policy explicitly prohibited the use of space heaters in resident areas and required specific interventions and monitoring in the event of HVAC failure. However, there was a lack of documentation of room temperatures and no evidence that alternative, policy-compliant measures were implemented to ensure resident safety during the heating outage. The incident was further compounded by delayed recognition and escalation of the resident's injuries, as well as inconsistent communication among staff regarding the presence and risks of the space heaters.