Lack of Supervision During Outdoor Fire Activity Results in Resident Burn Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to a resident during an outdoor activity involving a fire pit. The resident, who had diagnoses including major depressive disorder, anxiety disorder, COPD, schizoaffective disorder, and tremor but no cognitive impairment, was participating in a marshmallow roasting activity. Staff members were assigned to supervise different areas, but after assisting the resident with roasting a marshmallow, the dietary manager left the resident to assist others. The resident then returned to the fire pit alone, attempted to throw a napkin into what appeared to be an extinguished fire, and the napkin ignited while stuck to her hand, resulting in burns to her left hand and forearm. Other staff present were occupied with setting up a piñata and were not supervising the fire area at the time of the incident. The incident resulted in the resident sustaining second-degree burns, requiring immediate first aid and subsequent evaluation at a local emergency room. Interviews with staff revealed that supervision around the fire was not maintained after the initial activity, and there was confusion regarding who was responsible for monitoring the residents near the fire pit. The facility was unable to provide a policy regarding supervision of residents during outdoor activities.