Failure to Prevent Accident Hazards Related to Personal Hot Plate Use
Penalty
Summary
The facility failed to ensure a resident environment free from potential accident hazards for one of three residents reviewed. Facility policy required that every effort be made to keep the resident's environment as free of accidental hazards as possible. A review of the clinical record for a resident with diagnoses including diabetes, renal insufficiency, and high blood pressure revealed no assessment, risk identification, ongoing evaluation, or physician's orders regarding the use of a personal hot plate warmer for coffee cups at the bedside. The resident's care plan indicated a need for 24-hour care and supervision due to limited mobility and self-care deficits. During observation, the resident was found sitting on the bed with a small hot plate device on the bedside stand, actively in use to keep coffee warm. Interviews with the resident confirmed the use of the device, and facility leadership acknowledged the presence of the hot plate and the lack of appropriate safety measures. The facility confirmed that the environment was not free of potential accidental hazards for this resident.