Failure to Prevent Resident Burn from Baseboard Heater
Penalty
Summary
The facility failed to identify and implement interventions to prevent a resident from being burned by a baseboard heater in the lounge area next to the nurses' station. The lounge contained two metal baseboard heating units beneath large windows, each with accessible temperature control knobs and warning stickers indicating high temperatures. Staff interviews and record reviews revealed that the resident, who had intact cognition and diagnoses including malignant colon cancer, diabetes, and heart disease, frequently sat in this area due to feeling cold and was able to move her wheelchair independently. On the day of the incident, the resident reported right hand pain after warming her hand on the heater, which was found to be red and swollen. The baseboard heater's metal surface was later measured to reach temperatures up to 130 degrees Fahrenheit, exceeding the threshold capable of causing burns. Prior to the incident, staff were unaware that the baseboard heaters posed a burn hazard or that the temperature knobs were accessible and could be adjusted. The heaters had not been identified as an accident hazard, and no proactive measures had been taken to prevent such incidents. Other residents also regularly sat in the same area, but no previous burns had been reported. The facility's Accident Prevention and Resident Safety policy was requested, and an Accident and Incidents Investigating and Reporting policy was provided.