Burn Injury from Bed Placement Next to Baseboard Heater
Penalty
Summary
The deficiency involves the facility’s failure to ensure the resident’s bed was positioned to avoid contact with a nearby metal baseboard heater, creating an accident hazard that resulted in a thermal burn to the resident’s right great toe. The resident had diagnoses including Alzheimer’s disease, type 2 diabetes mellitus with neuropathy, peripheral vascular disease, and cerebral atherosclerosis, and was on hospice services. An MDS assessment documented moderately impaired cognition and a need for substantial/maximal assistance with rolling in bed. Due to neuropathy, the resident did not have sensation in the feet or lower legs and was therefore unaware of the burn while the toe was in contact with the heater. On the morning of the incident, an LPN began the shift and conducted rounds at approximately 6:45 AM, observing the resident sleeping on their side with the right foot lying over the left foot. The LPN called the resident’s name, obtained a response, and noted no signs of distress, but did not identify that the resident’s foot was on or near the heater. Within approximately 10–30 minutes, a CNA entered the room to provide ADL care and discovered the resident’s right great toe had been resting on the baseboard heating unit next to the bed. When the CNA removed the foot from the heater, bleeding was observed from the right great toe. Subsequent assessments documented a significant injury to the plantar surface of the right great toe. The LPN’s alert note described the toe as bloody and newly injured, with the resident appearing confused. The DON’s examination identified an open blister on the bottom of the right great toe measuring 4 cm by 3 cm with serous fluid, and an adjacent open area measuring 0.5 cm by 0.3 cm by 0.2 cm, with no sensation in the feet or lower legs. Hospice documentation and provider notes confirmed the injury as a burn to the plantar surface of the right great toe, with erythema, swelling, warmth, a dry denuded blister, and underlying hematoma. The facility’s own incident report and investigation identified that the bed had been placed adjacent to the wall-mounted heating register, and that this bed placement created the environmental hazard that led to the resident’s thermal injury while positioned in bed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.