Resident Burn Injury Due to Bed Placement Near Heater
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple medical diagnoses, including dementia and congestive heart failure, sustained a second-degree burn to his left knee while in bed. The resident was assessed as being at moderate risk for skin breakdown and was dependent on staff for all care. The incident occurred when the resident's knee came into contact with a metal radiator heating unit located directly next to his bed, which was positioned parallel and in close proximity to the heater. The heating unit's surface temperature was recorded at 126 degrees Fahrenheit. Staff interviews and observations revealed that the resident's bed was typically placed very close to the heating unit, with only a small space between the bed and the heater, making it difficult for staff to access the area. On the day of the incident, staff found the resident lying on his side with his knee resting on the heater. The resident did not report pain, but staff observed redness, a popped blister, and serosanguinous drainage on the knee. The resident was known to move himself in bed, sometimes repositioning himself after staff had assisted him. The facility's policy required employees to exercise maximum care and good judgment to prevent accidents and injuries, and to report unsafe conditions. However, the arrangement of the resident's bed in close proximity to a high-temperature heating unit created an accident hazard that was not addressed prior to the incident, resulting in the resident sustaining a burn injury.