Failure to Notify Physician of Resident's Burn Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's physician was promptly notified of a significant change in the resident's condition following a burn injury. The resident, who had moderately impaired cognition and required supervision with ambulation and assistance during meals, spilled hot coffee on their right hand while ambulating with a walker. The incident resulted in redness and later the development of blisters, but the attending physician and nursing supervisor were not immediately informed as required by facility policy. The initial response to the injury involved a CNA instructing the resident to submerge their hand in cool water and notifying an RN, who assessed the injury, provided first aid, and administered Tylenol for pain. The RN documented the incident in the huddle book but did not report the injury to the nursing supervisor or physician, nor did they provide a verbal report to the oncoming shift. The lack of communication led to a delay in physician assessment and treatment orders, as the physician only became aware of the injury two days later, at which point the resident was found to have sustained a third-degree burn with multiple blisters. Interviews with staff confirmed that the required notifications were not made, and documentation was incomplete or not reviewed by subsequent shifts. The DON and physician both acknowledged that the incident should have been reported immediately. The facility's own policy required prompt notification of the physician and supervisor for changes in a resident's condition, but this protocol was not followed in this case, resulting in a delay in appropriate medical evaluation and intervention.