Failure to Follow Heat Therapy Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice related to heat therapy. According to facility policy, hydrocollator temperatures should be checked daily, and specific procedures must be followed when applying heat packs, including wrapping the pack in layers of toweling, checking the resident's skin after application, and documenting the patient's response. Review of records revealed that a male resident developed a blister on his left shoulder after receiving heat therapy. The hydrocollator temperature was not checked daily as required, and the physical therapy associate did not routinely check the resident's skin during the application, only after the treatment was completed, which was not in accordance with facility protocol. Interviews and documentation indicated that redness was noted on the resident's shoulder after the heat therapy session, but no pain or discomfort was reported immediately post-treatment. The resident later experienced pain and was found to have a blister. There was no evidence that skin concerns were noted during the resident's scheduled bath/shower following the therapy. Additionally, facility records showed multiple dates where the hydrocollator temperature was not checked as per policy. The facility did not ensure daily temperature checks of the hydrocollator and did not accurately assess and report skin changes as required by their own procedures.