Failure to Maintain Safe Bed Distance from Heater Results in Resident Burns
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was placed a safe distance away from a wall heater, resulting in the resident becoming entrapped and sustaining second-degree burns. The resident involved had severe cognitive impairment, a diagnosis of neurocognitive disorder with Lewy Bodies dementia, anxiety, and a history of falls and self-transfers. The care plan indicated the resident required assistance with transfers and bed mobility, but was independent with rolling in bed. Despite these needs, the bed was positioned too close to the heater, with staff measuring the distance at only 11 inches at the time of the incident. On the morning of the incident, the resident was found between the bed and the heater, having rolled out of bed and come into contact with the heater. The resident sustained burns to the left hip and back, with multiple blistered areas and bruising on both knees. Staff interviews revealed that the bed had been near the heater for an extended period, and that the resident frequently attempted to get out of bed independently. Staff also reported that the heaters felt hot to the touch and that there was no prior education or consistent auditing to ensure beds were kept at a safe distance from the heaters. Documentation and interviews indicated that maintenance had previously performed a visual audit of bed placement but did not document the results or continue regular checks. Nursing staff were not routinely verifying bed distance from heaters, and there was no established policy or education regarding the required minimum distance prior to the incident. The lack of consistent monitoring and clear procedures contributed to the resident's ability to access the hazardous area and sustain injury.