The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and
§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Based on a review of clinical records, facility documentation, resident and staff interviews, it was determined that the
facility failed to implement interventions to prevent accident hazards for a resident (Resident R1) with a diagnosis of multiple sclerosis and with sensory impairment of the upper extremities, resulting in actual harm to Resident R1 laying on the heating unit and sustaining first and second degree burns of her left arm and left lateral breast for one of four residents reviewed (Resident R1).
Review of Resident R1's diagnoses list included diagnoses of multiple sclerosis (immune system disease which eats away the protective covering of nerves disrupting communication between the brain and body), neuritis (inflammation of a nerve,) first degree burn (top layer of skin), second degree burn (affecting the dermis which is below the epidermis) of left forearm, Paraplegia (paralysis to both lower leg), and Peripheral Vascular Disease (condition causing decreased blood flow to the extremities),
Review of the Resident R1's annual Minimum Data Set (MDS- assessment of care needs) dated November 30, 2019, identified the resident with a BIMS (Brief Interview of Mental Status) score of 12 out of 15 which indicated moderate cognitive impairment. Further review of the MDS assessment revealed that the resident required total assistance for transferring with the assistance of two people, had no ambulation capabilities and was unable to use the lower extremities.
Review of facility documentation dated January 5, 2020, revealed that Resident R1 was sitting in the dining room when the dietary aide, Employee E2 noted that the resident was bent over in her wheelchair and was not herself. Employee E2 lifted the resident's arm and saw blisters and notified staff to call the nurse. "Wound nurse saw several scattered fluid filled blisters approximately 2.2 centimeters x 1.3 centimeters." Employee E2 indicated that the resident was found with her arm resting on the heating unit. Further review of the facility documentation noted that the heater temperature was set at 80 degrees Fahrenheit.
Review of the report submitted to the State agency dated January 5, 2020, revealed that Resident R5 sitting next to Resident R1 indicated that Resident R1 was "looking out the window talking then she was out." When the resident was asked about the incident, she indicated that "she was sitting by the PTAC (PTAC- Pass Through Air Conditioning unit- self contain wall mounted unit that provide both air conditioning and heating to a single zone) because of the warmth; she had on short sleeves at the time."
Review of nursing note dated January 5, 2020, at 10:45 a.m. noted "Resident has been transferred to wheelchair with the total assistance of two CNA's (nursing assistant). Resident is AAOx3 (alert and oriented to people, place and time), has no complaints of pain or discomfort...is getting on the elevator to go to lunch. Will continue to monitor."
Review of nursing note dated January 5, 2020, at 12:35 p.m. revealed "Resident found lethargic leaning against heater in main dining room. resident was easily aroused when name was called. resident was noted to have multiple scattered closed fluid filled blisters on left forearm to elbow, when asked about pain resident denied. resident was transferred to bed by staff, was seen by supervisor on shift, wound nurse and charged nurse. resident could answer simple questions but was delayed in answer and falling asleep while answering... MD (physician) made aware and made verbal order to send resident out."
Review of nursing notes dated January 5, 2020, at 3:44 p.m. confirmed that the resident was transferred to the local hospital. Review of nursing notes dated January 5, 2020, at 5:38 p.m. confirmed that the resident was admitted to the hospital with the diagnoses of urinary track infection and first degree burn to left arm.
Review of nursing documentation dated January 7, 2020, at 7:54 p.m. revealed that the resident was re-admitted to the facility with the diagnosis of "second degree burn of multiple sites of left extremity...treatment in place as ordered. Wound care in place. Resident denies any pain at the moment."
Review of the resident visit with the physician dated January 13, 2020 following hospitalization revealed that Resident R1 was seen by the physician for a second degree burn of multiple sites of left upper extremities.
Review of Resident R1's January 2020, Medication Administration Record revealed that the resident was ordered to start treatment on January 8, 2020, of Silver Sulfadiazine (medication used to treat wound infections in patients with burns) 1% cream, apply topically daily to burns on left arm and left breast.
Interview on January 29, 2020, at 2:20 p.m., with Employee E2 a dietary aide working January 5, 2020, who reported that while pouring drinks for lunch she noted that Resident R1 was lying directly on the heater. When asked if she was all right the resident responded "yes" but slumped back down onto the heater. The dietary aide with the help of a nursing assistant in the dining room was able to straightened the resident upright in her wheelchair, and returned her to her unit.
Interview with licensed nursing staff, Employee E3 on January 27, 2020, at 2:35 p.m. indicated that the resident was not responding like normal, instead with more confusion. Her arm was reddened and very hot to touch, cool compresses were applied to the affected areas of the outer left arm and left breast area, When the skin cooled down non-adherent dressings were applied to the affected areas. Licensed nursing staff, Employee E3 further stated that the resident was her normal self before going to lunch, her blood pressure was assessed prior to administering her medication, and was within normal limits.
Interview with the Director of Nursing on January 24, 2020, at 2:00 p.m., revealed that the resident was not dressed in warm clothing, that she had short sleeves on, and is usually oriented with some confusion.
Interview with nurse aide, Employee E4 on January 27, 2020, at 3:10 p.m., revealed that the resident's family does her laundry, and that only short sleeves tops were found in her closet. When asked if the resident had a jacket, Employee E4 indicated she did not have a jacket.
Interview with the Maintenance Director on January 24, 2020, at 2:00 p.m. confirmed that he tested the unit and it was set at 80 degrees Fahrenheit.
Interview with the resident on January 24, 2020, at 10:30 a.m. revealed when asked about the incident and her burns her only reply was, "That's what they say." The resident was unable to indicate any remembrance or specifics of the incident.
Interview with Resident R5 who had been seated next to Resident R1 in the dining room, reported on January 27, 2020, at 3:30 p.m., that "she was leaning on the heating unit talking to her as she looked out the window, and then she went out."
An interview with Director of Nursing on January 27, 2020, at 2:00 PM, reported that the resident was transferred to the hospital related to confusion and multiple scattered closed fluid filled blisters of left breast area and left outer arm. The resident was kept in the hospital for observation (23 hours), and returned with orders for Silvadene 1% to be applied to the burn (second degree) area of the left arm which measured 27 centimeters x 13.6 centimeters x 0.1 centimeters, and the breast area described on the wound report as a reddened (first degree burn) area measuring 2.5 centimeters X 1.0 centimeters.
The facility failed to ensure that Resident R1 with a diagnosis of multiple sclerosis and with sensory impairment of the upper extremities, was kept at a safe distance to prevent direct contact with the heating unit which resulted in the resident laying on the heating unit for warmth and sustaining first and second degree burns of her left arm and left lateral breast.
28 Pa. Code 201.18 (b)(1) Management
Previously cited 2/06/19, 10/24/19
28 Pa. Code 211.10(d) Resident care policies
Previously cited 2/6/19
28 Pa. Code 211.12 (d)(1) Nursing services
Previously cited 2/06/19
28 Pa. Code 211.12 (d)(5) Nursing services
Previously cited 2/06/19
| ||Plan of Correction - To be completed: 01/28/2020|
The facility submits the following Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or to challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violations of State and Federal regulatory requirements.
Resident was evaluated by nurse supervisor and first aid was administered at time of event. She was sent to the hospital for further evaluation and treatment per Physician order.
Residents in the dining room were evaluated for proximity to the PTAC units, no residents were found to be in close proximity to the units. PTAC units in dining rooms were evaluated by Maintenance Director and were functioning appropriately.
Rearrangement of dining room tables in front of PTAC units was done as temporary measure to prevent resident access to PTAC units. Protective covers were permanently placed on top of PTAC units in dining room. Residents will not be able to lean over/against units with covers in place.
Staff in all departments educated to monitor residents while in dining rooms to prevent residents from leaning against PTAC units.
Q shift check, daily x2 weeks of placement of covers will be completed. Audit will be completed of q shift checks of placement of covers. Results of the audits will be reviewed at the QAPI meeting monthly x3 for review and compliance. Maintenance Director or Designee will be responsible for audits and NHA will monitor compliance.