VILLAS OF SHANNON
Facility I.D. Number 0043851
Date of Survey: 02/13/02
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
These requirements are not met as evidenced by:
Based on interview, observation and record review, the facility failed to maintain the resident environment free of accident hazards. One resident had a space heater in their room. The resident received third degree burns on 5% on his body from a fall on the space heater on 2/4/02.
This is for 1 of 5 residents in the sample (R1).
The findings include:
On 2/7/02 at 11 a.m. in the conference room, E4 was interviewed. E4 stated, "On 2/4/02, I made rounds on the East hall approximately 7:30 p.m. (R1) was lying in bed. I didn't see the space heater. At 9 p.m., I was standing in the Center hall and I heard a resident calling out for help. I thought it sounded like a female voice. I went and checked the female end first. No one down there was calling out for help. I then checked the male end. (R1) was lying on the space heater. His left side was on the space heater. I removed the heater. The heater was hot. (R1) had a laceration in the center on his head which was bleeding. I called for help. (E5) came and helped me get (R1) to bed. We removed his (R1's) shirt and found his left side from under the arm to lower ribs red and blistered. (R1) wouldn't let us touch him. He said it hurt a great deal. It was very painful."
On 2/7/02 at 11:30 a.m. in the conference room, E5 was interviewed. E5 stated, "On 2/1/02, I was told to remove all space heaters. I didn't remove (R1's) because he would get mad and agitated. I saw (R1) on 2/4 approximately at 8:30 p.m. and then again sometime after 10 p.m. (R1's) left side was burned from thespaceheater.()complained of pain and wouldn't let us touch him."
Review of an incident report dated 2/5/02 revealed, "(R1) fell in his room approximately 10:40 p.m. The nurse reported he was lying on his left side on top of a portable heater. Laceration to the forehead with minimal bleeding. Noted a 9 x 7 reddened area on the left thoracic area."
Review of R1's minimum data set dated 11/7/01 revealed, R1's speech unclear, may miss some part/intent of message and balance unsteady. Review of R1's care plan dated 11/7/01 revealed, increased falls, limited mobility, generalized weakness, and unsteady gait with approach to include: assist with all transfers.
On 2/9/02 at 11:30 a.m., Z7 was interviewed per telephone. Z7 stated, "I was notified on 2/5/02 about 1 p.m. that (R1) had an incident. I understand that a space heater was in his room and he fell on it. He received third degree burns on 5 percent of his body."
Consultation report dated 2/06/02 by Z10 was reviewed and stated, "Apparently (R1) fell onto a space heater at the nursing home and apparently he was on the heater for approximately 45 minutes before he was removed. He suffered a burn wound to the left anterior chest wall. The burn area measures approximately 15.0 x 18 cm. It is located toward the left side of the chest wall. The central portion of the wound appears to be a third degree burn. The overall total body surface area burn I believe not more than 5 %."
On 2/7/02 at 10 a.m., E1 was interviewed in the conference room. E1 stated, "I was not aware that (R1) had a space heater in his room until 2/4/02 after the incident. IDPH was notified on 1/30/02 of the heating problem and use of the space heaters. The heaters were to be removed on 2/1/02 by staff."