F0609

D

Failure to Timely Report Significant Burn Injury as Alleged Neglect

Wabasso, Minnesota Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The facility failed to immediately report an allegation of neglect involving a resident who sustained a significant burn injury from hot liquid. The resident, who had intact cognition, ambulated independently with a walker, and was independent with eating, had diagnoses including diabetes, peripheral neuropathy, malnutrition, and anxiety. Progress notes documented that the resident spilled hot water on the right upper thigh, resulting in visible redness, and was educated to be careful with hot liquids and to ask for help when needed. A physician ordered Vaseline to the affected area and pain medication. The following day, documentation showed a reddened area with a blister approximately five inches by three inches, and the provider ordered Xeroform dressings, ABD pad, Kerlix, and added the resident to wound rounds.

Despite these findings and the development of a large blistered area, the facility did not report the incident to the State Agency within the required two-hour timeframe for events involving alleged abuse or resulting in serious bodily injury, as required by its Abuse, Neglect, and Exploitation Policy. A later hospital wound care consult identified a partial thickness burn on the resident’s right thigh measuring 15 x 26 x 0.1 cm, described as blistered, fragile, bleeding, and erythematous, and requiring chemical and mechanical debridement. The DON stated she was notified of the burn on the date of occurrence but did not consider it significant until several days later and confirmed the burn was not reported to the State Agency. The administrator also confirmed that although staff notified him immediately after the incident, it was not reported to the State Agency, and there was no evidence the facility assessed residents for mitigation of hazards related to hot liquids prior to this event.