Failure to Supervise and Protect Resident from Environmental Hazard Resulting in Severe Burns
Penalty
Summary
A deficiency occurred when staff failed to identify and mitigate an environmental hazard and provide adequate supervision for a newly admitted resident who was severely cognitively impaired and blind. The resident, who had a history of vascular dementia, frequent falls, and glaucoma, was placed in his wheelchair near a lit fireplace in the dining room after expressing that he felt cold. The nurse aide assigned to him left the resident unsupervised to assist another staff member, leaving the resident alone in close proximity to the hot fireplace. While unattended, the resident tipped his wheelchair backward, falling against the fireplace. His head, back, and shoulders came into contact with the hot mesh grate, resulting in second-degree burns with blistering to the back of his scalp, right shoulder, upper back, and left index finger, as well as a hematoma to the back of his head. The resident experienced severe pain, required emergency medical services, and was hospitalized for wound care and pain management. The incident was witnessed by another resident, who called for help, and staff responded after hearing the resident's cries. The facility lacked safety precautions to prevent residents from accessing or activating the fireplaces or coming into contact with the hot surfaces. There were no physical barriers, safety gates, or lockout features on the fireplaces, and staff had not received training or education regarding fireplace safety. The operational switches for the fireplaces were accessible to residents, and staff and residents were observed to regularly turn the fireplaces on and off. The environmental hazard was not recognized or addressed prior to the incident, and the resident was left unsupervised despite being identified as a high fall risk and having significant cognitive and visual impairments.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance