Neglect Resulting in Severe Electrical Burns Due to Unsafe Use of Power Strip
Penalty
Summary
A deficiency occurred when a resident with paraplegia, bilateral leg amputations, and a neurogenic bladder sustained third-degree burns to 4% of his body after urine from a self-catheterization or incontinence episode contacted an energized power strip that was positioned in his bed. The resident, who was functionally dependent for many activities and had a history of incontinence, was provided a power strip by the facility administrator after his extension cord was removed. There was no documented assessment of the resident's ability to safely use the power strip, nor was there any care plan addressing the risks associated with electrical devices in the bed, despite the resident's known incontinence and use of multiple electronic devices in bed. Staff interviews and medical record reviews revealed that the resident frequently kept electronics, charging cords, and other items in his bed, and staff were aware of his incontinence and the risk of spillage during self-catheterization. Multiple staff members, including CNAs and nurses, observed the power strip in the bed and reported safety concerns to administration, but there was no evidence of consistent monitoring, intervention, or documentation of the resident's refusals or noncompliance. The care plan did not include interventions related to the safe use of electrical devices, noncompliance behaviors, or monitoring of self-catheterization competency, even though the resident was receiving medications that could cause drowsiness and further increase risk. On the day of the incident, the resident self-catheterized and subsequently experienced an electric shock, resulting in severe burns. The power strip was found melted and deformed, and the resident required emergency medical attention. Staff confirmed that no education or monitoring regarding the safe use of electrical devices in bed had been provided prior to the incident. The facility's failure to assess, monitor, and implement appropriate interventions to prevent physical harm constituted neglect and resulted in actual harm to the resident.