Failure to Prevent Severe Burns Due to Bed Placement Near Radiator
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia, heart failure, and cerebrovascular disease suffered severe burns after falling out of bed and coming into contact with a radiator heater. The resident's bed had been positioned against the wall, adjacent to the radiator, which was a standard room setup for two residents in the facility. The resident had a history of falls, confusion, and required assistance with bed mobility and transfers, as documented in care plans and assessments. On the night of the incident, the resident was last seen by staff at approximately 2:30 AM and was found around 3:00 AM lying on top of the radiator after a loud noise was heard from the room. Upon assessment, the resident was found to have burns on the right cheek, right arm, and right leg, with subsequent medical evaluation confirming first, second, and third-degree burns. The burns were severe enough to require hospitalization in an intensive care unit specializing in burn care for five days. Staff interviews revealed that the bed was placed against the wall due to room size constraints and that this was a common practice. The radiator cover had become dislodged during the fall, exposing the resident to the hot surface and resulting in the burns. Maintenance staff were not routinely checking the radiators unless issues were reported, and there was no prior awareness of burn incidents related to the radiators. Documentation and interviews indicated that the resident was at high risk for falls due to cognitive impairment, impaired mobility, and a recent history of falls. The care plan included interventions such as floor mats and one-person assistance for bed mobility, but did not address the hazard posed by the proximity of the bed to the radiator. The facility's failure to identify and mitigate the environmental hazard of the radiator heater, combined with inadequate supervision and monitoring of bed placement, directly led to the resident's injuries.
Removal Plan
- Resident R2's bed was moved away from the wall and heating unit.
- The Maintenance director/Designee completed rounds to ensure that all heating units are working adequately, and all beds are moved away from the heating unit/Wall.
- All staff were provided with education by the Maintenance director/Designee, training including but not limited to ensuring the positioning of beds are away from the heating unit/Wall.
- The Medical Director, Administrator, DON and Maintenance director reviewed the facility's policies which include but are not limited to: Guidelines on preventative maintenance measures.
- New hires will be in-serviced by the Maintenance, or Designee.
- All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work.
- The facility does not utilize agency staff however the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift.
- The Maintenance director/designee will conduct audits to identify any potential concerns related to this plan of removal.
- During the weekends and holidays, the Maintenance director/Designee will conduct the audits, ensuring beds are away from the heating units. Any identified concern will be addressed immediately.
- To ensure compliance, the results of the audit will be reviewed during the meeting which is attended by the leadership which includes but is not limited to the: DON, ADON, Maintenance director and the Administrator/Designee.
- The Maintenance/Designee will conduct random staff interviews for at least 5 employees to gauge knowledge for retention and determine if additional training is required.
- Any identified concern will be addressed immediately and will also be discussed during the Adhoc QAPI.
- All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance.
- The Administrator, Maintenance director and Designee will monitor completion of this plan of removal.