Failure to Prevent Accident Hazard from Unauthorized Heating Pad Use
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to notify the nurse that a resident was using a heating pad. The resident, who had multiple diagnoses including diabetes, kidney disease, chronic pain, and a recent surgical amputation, was found unresponsive by a registered nurse (RN) during a medication pass. The RN discovered hot compresses under the resident's gown and was unaware that the resident had access to a heating pad. The CNA had observed the heating pad earlier but did not check if it was on or report its presence to the nurse. There was no documentation indicating that the nurse was informed about the heating pad or that it was placed behind the resident. The resident was subsequently found to have a burn and required hospital care for the injury. The incident report and staff interviews confirmed that the CNA did not follow protocol by failing to communicate the use of the heating pad to nursing staff. The resident's medical record also lacked documentation of the heating pad's use or any related skin issues prior to the incident. The director of nursing (DON) confirmed that the CNA should have reported the heating pad but did not do so.