Failure to Monitor and Document Safe Use of Portable Heaters
Penalty
Summary
The facility failed to ensure that portable heaters were safe and adequately monitored in the Memory Care unit, affecting nine residents directly and potentially impacting all 19 residents in the unit. Multiple residents with severe cognitive impairment, physical disabilities, and dependence on staff for activities of daily living were exposed to oil radiator and ceramic space heaters that were extremely hot to the touch and set to maximum heat, while room temperatures remained at 71-72 degrees Fahrenheit. There was no documentation in the medical records of any safety monitoring related to the use of these space heaters for any of the affected residents. Observations confirmed the presence of multiple space heaters in resident rooms, with exposed metal surfaces that became extremely hot within less than a second of contact. The Director of Maintenance verified the use of these heaters in several rooms and acknowledged that residents were typically in common areas during the day, but there was no established or documented process for monitoring either the heaters or the residents for safety. Staff interviews further revealed that there was no ongoing or documented monitoring of residents or the space heaters since their implementation, and staff training on the use and monitoring of the heaters was only verbal and undocumented. Review of manufacturer instructions for the heaters indicated that they posed risks of fire, electric shock, and injury, especially for individuals with reduced physical, sensory, or mental capabilities. The facility's existing policies did not provide guidelines for the use of portable heaters, and the policy addendum for emergency use of space heaters was only adopted after the deficiency was identified. Prior to this, there was no documentation of safety rounds, inspections, or staff education regarding the use of space heaters in resident rooms.