Failure to Provide Adequate Supervision Resulting in Resident Burn Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision for a resident, resulting in the resident sustaining a full thickness burn on his left leg with a surface area of 136.90 cm^2. The incident was discovered when a staff member noticed the burn during a routine activity and sent the resident back to his floor. Multiple staff interviews revealed that no one knew how or when the injury occurred, and the resident, who is nonverbal and has severe cognitive impairment, was able to move independently between floors using the elevator without direct supervision. The resident's medical history included deafness, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease, and chronic systolic heart failure. Documentation showed that the resident had severely impaired cognitive skills for daily decision making and memory problems. Despite these vulnerabilities, staff were unclear about the resident's whereabouts and level of supervision at the time of the injury. The wound was described as severe and required specialized wound care. Facility leadership, including the DON and administrator, were not notified of the injury in a timely manner, and no investigation or report to the State was initiated as required by facility policy. The injury was classified as of unknown origin, which should have triggered an abuse investigation and mandatory reporting. Staff interviews confirmed that the resident was not adequately supervised, and the facility failed to follow its own policies regarding accident prevention, supervision, and incident reporting.