Burn Injury from Radiator Due to Inadequate Hazard Control and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment free of accident hazards and to provide adequate supervision and assistive devices to prevent avoidable accidents, resulting in a burn injury to one resident. The resident had diagnoses including dementia, anxiety disorder, and a seizure disorder, and the most recent Quarterly MDS documented moderately impaired cognition. The MDS and CNA documentation showed the resident required total assistance with transfers and toileting, used a Hoyer lift with two-person assistance for transfers, and needed substantial/maximal assistance with rolling in bed, indicating significant dependence for bed mobility and positioning. On the morning in question, the resident was observed with erythema on the left upper thigh extending to mid-thigh, approximately 15 cm by 8 cm, with irregular shape, uneven borders, bright pink to red coloration, and blistering in the mid-region. Nursing assessment documented that the resident appeared to have been lying with the thigh on a heating vent, although no staff witnessed this. The RN Supervisor later described the wound as a dark pink rectangular-shaped line on the left upper thigh with a small blister in the center, measuring 15 cm by 8 cm, and stated that the pattern of the lines on the resident’s thigh matched the line patterns on the top of the radiator. The physician who assessed the wound stated it could be a second-degree burn caused by a hot surface such as a radiator and that, if caused by the radiator, it would be avoidable. Staff interviews revealed that multiple CNAs and nursing staff had provided care and rounding for the resident before the burn was discovered, and that the resident was known to require extensive assistance with mobility and had poor awareness of bed boundaries. CNAs reported performing rounds and incontinence care during the night and early morning, stating that the resident’s bed was not close to the radiator and that they were able to walk around the bed. They also reported that the resident remained in the same position after being turned and that no redness was observed on the legs or thighs during earlier care. However, the facility’s incident investigation later concluded that, due to the resident’s poor awareness of bed boundaries and the alternating pressure of the air mattress, the resident likely shifted or rolled toward the radiator, resulting in the burn. This sequence of events demonstrates that the facility did not adequately control environmental hazards related to the radiator and did not ensure sufficient supervision and protective measures to prevent the resident from coming into prolonged contact with a hot surface.
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