Failure to Prevent Burns Due to Inadequate Monitoring and Unsafe Placement of Baseboard Heaters
Penalty
Summary
Surveyors identified that the facility failed to ensure resident environments were free from accident hazards by not having a system in place to monitor the surface temperature of baseboard heaters and by failing to maintain safe distances between resident beds and these heaters. Multiple residents with impaired mobility and/or cognition were found to have their beds either touching or within a few inches of baseboard heaters, some of which were measured at temperatures significantly above the 125°F threshold considered acceptable for LTC settings. Manufacturer documentation and state guidance both indicated that objects, including beds, should be kept at least 12 inches away from baseboard heaters to prevent burns and other injuries. One resident with severe cognitive and mobility impairments fell out of bed and became trapped between the bed and the wall, coming into prolonged contact with a baseboard heater and sustaining partial thickness (second-degree) burns. This resident had a history of falls, impaired sensation, and required assistance for mobility. The incident occurred when the resident rolled out of bed, and the heater's surface temperature was not being monitored or logged by facility staff. Other residents with similar risk factors were also observed to have beds in direct contact with or very close to baseboard heaters, with measured surface temperatures ranging from 127°F to 169°F. Some residents reported that the heaters were extremely hot to the touch, and staff interviews revealed inconsistent knowledge about required safe distances between beds and heaters. The facility did not have policies or procedures in place to ensure regular monitoring of heater surface temperatures or to ensure that beds and other combustible materials were kept at safe distances from heaters. Staff were not uniformly aware of the risks or the manufacturer's recommendations, and there was no evidence of routine audits or temperature checks prior to the survey. The lack of a systematic approach to identifying and mitigating these hazards resulted in at least one resident sustaining burns and placed other residents at risk for serious harm.
Removal Plan
- Bed was moved away from the heat register for affected resident (R3).
- A larger 42-inch bed was provided to R3 to prevent future falls.
- The baseboard heater in R3's room was replaced with a newer style heater as a precaution.
- R7's bed was moved to the other side of the room away from the heat register.
- Care plans were updated to include instructions to keep beds away from heat registers.
- Re-education of all staff was provided regarding keeping residents and beds away from heaters.
- Ambassador rounds were completed to ensure all beds were moved away from registers.
- Audit of rooms was conducted to check register temperatures with an infrared thermometer.
- All resident rooms were checked and beds closer than 1-2 feet from registers were adjusted.
- Care profiles were updated for staff to check bed/personal item placement in relation to registers.
- All room heat registers had their temperature checked and confirmed to be within manufacturer specifications.
- Rooms were rechecked for bed placement away from registers.
- One resident was moved to another room when their room could not be rearranged to meet safety requirements.
- Audits were created to monitor heat register temperature, room temperature, and corrections for heat registers.
- Audit protocol was created for placement of beds away from registers.
- Random temperature audits of registers to be completed, with all audits reviewed at QAPI.
- NHA or designee to complete bed positioning audits at the same frequency as temperature audits, with review at QAPI.
- QAPI meeting held to review plan, root cause, and ensure compliance with F689.
- Baseboard Heat Registry Protocol implemented: Residents and beds to maintain a safe distance from baseboard heat registers; recliners positioned safely; concerns reported to Maintenance Lead or Administrator for prompt follow-up.