Failure to Prevent Burn Injury Due to Unauthorized Appliance
Penalty
Summary
A resident with paraplegia and generalized muscle weakness sustained a second-degree burn to the left thigh after using an unauthorized egg cooker in their room. The resident, who was cognitively intact and required partial to moderate assistance with activities of daily living, reported burning themselves while cooking eggs. The burn was not immediately reported to staff, and the resident waited several days before seeking treatment, at which point a partial thickness wound was identified and treated per physician order. Facility staff, including an LVN, DON, and Administrator, were aware at various times that the resident possessed an egg cooker in their room. The LVN observed the egg cooker during routine care but did not report its presence until after the burn occurred. The DON believed the egg cooker had been removed but did not verify this, and the Administrator instructed the resident not to keep the appliance but did not confirm its removal due to the resident's behavior and concealment of the device. No staff member assessed the egg cooker for safety, provided written approval for its use, or ensured the resident received instruction on safe operation of the appliance. The facility failed to follow its own policy and procedure regarding electrical appliances, which required written authorization and safety checks for any such devices in resident living areas. The policy specifically prohibited residents from maintaining heating or cooking devices in their rooms unless approved in writing by the Administrator or designee. The lack of enforcement and oversight of this policy directly contributed to the resident's injury.