Burn Injury from Unauthorized Homemade Hot Pack Applied by CNA
Penalty
Summary
The deficiency involves the facility’s failure to prevent a burn injury caused by an unsafe, homemade hot pack applied to a resident’s left outer knee. The resident had multiple medical conditions, including COPD, mild protein-calorie malnutrition, type 2 diabetes mellitus, hereditary and idiopathic neuropathy, and later multiple rib fractures and acute respiratory failure, and had mild cognitive impairment with a BIMS score of 11/15. Following a fall, the resident reported bilateral knee discomfort and pain in the left knee. On the day after the fall, nursing documentation noted a new water blister on the resident’s left outer knee, and the wound was entered on the facility’s wound log as a blister/burn measuring 3.5 cm by 3 cm. The wound physician later documented a full-thickness burn wound of the left lateral knee, with duration greater than seven days, and noted that the resident had been using a heating pad for knee pain and suffered a thermal burn. Interviews and record review showed that the resident later reported the burn was caused by a hot pack placed on the outer knee that felt like it was burning, but the resident thought it was helping the pain. The administrator confirmed that homemade hot packs should never be used, that CNAs are not allowed to apply any type of heat application, and that heat packs require a physician’s order and must be applied by licensed nursing staff or therapy. The wound physician stated he was not aware the burn was caused by a homemade hot pack applied by staff and affirmed that only specific, safe products with a physician’s order should be used, and only by licensed nursing staff. The ADON initially assumed the blister was due to edema and treated it as a fluid-filled blister without any report of hot pack use, and only later learned from the resident that a CNA had applied a hot pack. The CNA admitted making and applying homemade hot packs at the resident’s request by using hot water from a coffee maker on washcloths, placing them in a plastic biohazard bag, wrapping them in pillowcases, and placing them directly on the resident’s skin, and stated she was unaware CNAs were not allowed to apply hot packs. The facility was unable to provide any policy or procedure addressing resident heat application, and the CNA job description only generally required reporting complaints and using only equipment for which the CNA had been trained.
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