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Based on policy review, medical record review, and interview, the governing body failed to ensure nursing staff followed written polices and protocols for patient care when 1 of 3 (Patient #1) sampled patients developed a hospital acquired burn from an improper application of heat therapy, resulting in first and second degree burns.

The findings included:

1. Review of the hospital policy "K-Pad Aquamatic" last revised 11/16/2005 revealed, "...PURPOSE: To provide dry or moist heat with a controlled temperature setting. POLICY: A physican's order is required for the use of the K pad. PROCEDURE: A. Equipment- Aquamatic K Module Distilled water B. Procedure- A. Attach K module and place both on same level. Fill container with distilled water...B. Tilt module slowly from side to side and end to end to allow air bubbles to escape. C. plug module into AC outlet, turn module on and allow to run for two (2) minutes. Allow entire system to fill. D. Turn module off and refill reservoir with distilled water...E. Explain procedure to patient. F. Pad may be applied directly to the affected area. If moist heat is desired, apply moistened dressing to area before applying K Pad. G. Turn on module. Lace pad gently around extremity. Pad may be covered with a pillowcase...H. Make certain that tubing is not pinched off. Pinching off tubing will cause circulation to stop and pad will not heat. I. Turn off switch before disconnecting pad..."

2. Medical record review for Patient #1 revealed an 82 year old male who presented to the hospital Emergency Department on 11/5/2022 after a fall, mental status changes and overall physical deterioration. Patient #1 was admitted to the hospital for acute care. On Patient #1 was transitioned the hospital's swing bed for skilled therapy services.

On 12/4/2022, Patient Care Technician #1 initiated heat therapy to Patient #1's Left shoulder and upper arm by using a disposable ice pack filled with hot water from a industrial coffee pot. On 12/4/2022 at approximately 11:00 PM, PCT #1 discovered a reddened, burned area where the heat pack had been applied. The burn wound measurements were documented on 12/4/2022 as "Length 22.5 cm [centimeters], Width 19 cm (8 cm X [by] 13 cm- chest) (14.5 cm X 19 cm-shoulder)...1st degree, 2nd degree Redness and Blisters..."

Patient #1 required antibiotic treatment to prevent infection, multiple wound treatments, daily dressing changes, debridement and pain medication as a result of the hospital acquired burn.

Refer to C 962

Based on policy review, medical record review, and interview, the governing body failed to ensure nursing staff followed written polices and protocols for patient care when 1 of 3 (Patient #1) sampled patients developed a hospital acquired burn from an improper application of heat therapy, resulting in first and second degree burns.

The findings included:

1. Review of the hospital policy "K-Pad Aquamatic" last revised 11/16/2005 revealed, "...PURPOSE: To provide dry or moist heat with a controlled temperature setting. POLICY: A physican's order is required for the use of the K pad. PROCEDURE: A. Equipment- Aquamatic K Module Distilled water B. Procedure- A. Attach K module and place both on same level. Fill container with distilled water...B. Tilt module slowly from side to side and end to end to allow air bubbles to escape. C. plug module into AC outlet, turn module on and allow to run for two (2) minutes. Allow entire system to fill. D. Turn module off and refill reservoir with distilled water...E. Explain procedure to patient. F. Pad may be applied directly to the affected area. If moist heat is desired, apply moistened dressing to area before applying K Pad. G. Turn on module. Lace pad gently around extremity. Pad may be covered with a pillowcase...H. Make certain that tubing is not pinched off. Pinching off tubing will cause circulation to stop and pad will not heat. I. Turn off switch before disconnecting pad..."

2. Medical record review for Patient #1 revealed a 82 year old male who presented to the hospital emergency department on 11/5/2022 at 3:40 PM via emergency medical services with complaints of fall prior to arrival with progressive weakness.
Patient #1 was admitted to the hospital on 11/6/2022. Review of the hospital History and Physical revealed, "...82 year old M [male] presented to ER [emergency room] yesterday after a fall day prior. There was no LOC [loss of consciousness] and CT [computerized tomography] Head WNL [within normal limits]. Pt [patient] has worsening dementia and unable to care for self....CT CAP [chest abdomen pelvis]showed some small bilat [bilateral] pleural effusion and cholelithiasis w/o [without] cystitis...Discussed with pt he would need eval [evaluation] by PT and likely need placement in a facility...PLAN: Will admit to hospital pending assessment by PT and likely placement [skilled facility]..."

Patient #1 was admitted to hospital swing bed status on 11/11/2022 for skilled care with Occupational Therapy and Physical Therapy.

Review of a nursing note dated 12/4/2022 at 12:30 AM by RN #1 revealed, "Nurse called to patient's room after PCT [patient care tech] noted redness and blistering likely from warm pack. Patient was lying on his back. Towel that PCT had placed between patient's skin and warm pack reportedly had moved. Redness and blistering noted to L [left] upper anterior chest to L shoulder. Cool moist cloths immediately applied to affected areas. Nurse Supervisor [RN #2] was notified by PCT and came to room; supervisor notified on call physician [Physican #2]....New order received to apply Silvadene cream BID [twice daily] . Measurements of affected area taken, Silvadene has been applied...Patient denies pain /discomfort."

Review of the burn wound measurements dated 12/4/2022 at 1:30 AM revealed, Entire Wound- Length 22.5 cm [centimeters], Width 19 cm (8 cm X [by] 13 cm- chest) (14.5 cm X 19 cm-shoulder)...1st degree, 2nd degree Redness and Blisters..."

The following wound measurements were documented by nursing for Patient #1's burn/wound:
12/6/2022- Arm- 15 cm X 15 cm; Chest- 8 cm X 9.5 cm
12/11/2022- Shoulder/arm- 13 cm X 13 cm; Chest- 8 cm X 10 cm
12/13/2022- Shoulder/arm-10 cm X 6 cm; Chest-5 cm X 5.5 cm
12/14/2022- Shoulder- 10 cm X 6 cm; Chest- 5 cm X 5.5 cm
12/15/2022-Shoulder- 9.5 cm X 6 cm; Chest-6 cm X 5.5 cm
12/21/2022- Length 15 cm X Width 9 cm left shoulder left chest wounds
12/26/2022- Length 15 cm X 9 cm with an area approximately 6 cm X 3.5 cm blackened area in wound bed.

Review of physican orders revealed the following to treat Patient #1's hospital acquired burn wound:
12/5/2022- Doxycycline 100 milligrams (mg) capsule twice daily for 7 days to prevent infection of the wound
12/5/2022- Tylenol with codeine 100/30 mg every 6 hours as needed for pain and 30 minutes prior to dressing changes.
12/6/2022- Dressing change daily, clean with normal saline, apply Silvadene, dress with non stick and gauze
12/7/2022- in wound bed add adaptic (a non adhering wound dressing), then Xero foam (gauze) and optic form (silicone faced foam dressing) discontinue Silvadene cream
12/21/2022- change dressing every 2 days, clean with normal saline, apply sorbact (a hydrophobic microbe binding wound contact layer) to wound bed, cover with hydrogel (high water content to sooth and provide moisture to wound)

Review of Physican #1's progress notes revealed the following:
12/5/2022- [named Patient #1] is resting. He does have some burns to his left shoulder with a heating pad...Will continue Silvadene. Will also place him on antibiotics as well as pain control.

12/7/2022- "I examined his [Patient #1] wounds today. His arms are burned with 100% slough [dead tissue]. I gently used curettage [scraping to remove tissue] to remove some of the slough..."

12/9/2022- "...He does have a wound with burn on his left arm that is very red. Also has slough on it. Does have areas that are slightly hard at the top, does have some granulation around the edges approximately 7 inches by about 4 inches. Very irregular borders both on the arm and then also goes to the chest on a smaller area.

12/15/2022- "...Chest wall one is doing much better. It is healing well...still having some eschar at the very top. I removed all the dressings and used a #14 blade and slowly debrided the wound slightly. It was somewhat tough, so mainly I mildly got one layer off. He tolerated the procedure very well...The top is still black in color underneath its mucus. We can see on th edges there is some good tissue, some granulation, and it has some eschar..."

12/22/2022- "...Wound is approximately 10 X 15 cm on the arm. The one on the chest is considerably smaller...The one on his chest is healing...It does not really have much eschar, just some slough. The one on his arm does have some eschar. I did give him a pain pill before procedure as well as some topical Lidocaine. Debrided a good part of the eschar but not able to get completely down..."

Patient #1 was discharged to a skilled nursing facility on 12/27/2022 for continued therapy and wound care.

3. In an interview on 1/25/2023 at 1:30PM, the Nurse Manager (NM) stated she was informed of the incident for Patient #1 when RN #1 called her at home on 12/4/2022. The NM stated PCT #1 used an old cold pack, an older type ice pack to apply heat for Patient #1. The NM stated, "PCT #1 shouldn't have used it...got hot water from the coffee spicket and put it into the cold pack, used a towel barrier and put the pack on Patient #1." The NM stated the staff reported they had been using this method for several days for Patient #1. The NM stated the towel must have slipped and caused the burn on 12/4/2022. When asked if the medical record included any photos of the burn/wound, the NM stated, "It's not something that we do- we have no photos of the wounds." The NM further stated PCT #1 "Was let go [terminated]."

In a telephone interview on 1/26/2023 at 9:22 AM, Patient Care Technician [PCT] #1 verified she was working the night shift on 12/4/2022. PCT #1 stated she and RN #1, and another nurse had gone in to provide personal care to Patient #1 at the beginning of their shift and she observed Patient #1 grimacing when they were repositioning him. PCT #1 stated she asked RN #1 if it would be okay to apply heat to Patient #1's left shoulder and RN #1 told her that would be fine. PCT stated she got a large disposable ice bag [used to put ice in for cold therapy] and put water from the hot water spicket at the coffee machine in the nourishment room, set the ice pack with hot water aside and went to check on other patients. PCT #1 stated she went back to get the pack filled with hot water from the coffee machine approximately 15-20 minutes later. PCT #1 stated she took the pack and a towel into Patient #1's room where she positioned the towel on his left shoulder and then placed the heat pack on top of the towel to provide heat therapy. PCT #1 stated Patient #1 was positioned on his right side. PCT #1 stated it was approximately 8:20 when she applied the heat pack. PCT #1 stated she observed Patient #1's at approximately 9:45 PM and her had rolled to his back and appeared to be in no distress. PCT #1 stated at 11:00 PM, she went to make rounds and noticed the skin around the heat pack looked red and she observed a blister on his shoulder approximately the size of a golf ball. PCT #1 stated she reported the burn to RN #1 immediately. When asked who had trained her to use the hot water from the coffee machine in the ice bags to provide heat therapy, PCT #1 stated, "[named RN #3] told me to get hot water from coffee pot and use a towel [as barrier to skin]..." PCT #1 stated RN #3 had shown her that months before.

In a telephone interview on 1/26/2022 at 9:32 AM, Physican #1 verified he was notified on 12/5/2022 of the burn to Patient #1's shoulder caused by the heat pack applied by PCT #1. Physican #1 verified staff would need a physican order to apply heat or ice for a patient. When asked if that was an appropriate method to apply heat therapy, Physican #1 stated, "...not be appropriate to apply heat in that manner..." Physican #1 stated the burn wound did improve but when Patient #1 was discharged, the wound had not healed completely and he did require continued wound care at the skilled facility.

In a telephone interview on 1/26/2023 at 9:40 AM, RN #1 verified she was working on 12/4/2022 when Patient #1 received a burn as a result of the application of a heat pack. RN #1 stated PCT #1 asked if she could apply a heat compress to Patient #1's left shoulder because he had grimaced several times when he was repositioned. RN #1 stated, "I didn't know she was going to use the coffee water." RN #1 stated, " I want to say 3 hours later she [PCT #1] came to make me aware of the blister. RN #1 stated PCT #1 said "I burned him, I burned him." RN #1 stated she was unable to recall the exact size of the burned area, but she documented measurements on the same day of the incident.

In an interview on 1/26/2023 at 9:53 AM, RN #2 verified she was the hospital Nursing Supervisor and reported to the hospital Nurse Manager. RN #2 stated she was working as the emergency department(ED) charge nurse on 12/4/2022. RN #2 stated PCT #1 came to the ED crying on 12/4/2022 and reported she had placed a warm compress on Patient #1 and somehow it had slipped and caused redness and blistering. RN #2 stated she went to assess Patient #1. RN #2 stated there were a couple of blisters the size of a pen point, one blister the size of a nickel and one blister the size of a golf ball in the center. RN #2 stated Patient #1 denied any pain. RN #2 stated she informed Physican #2, the on call physican, who ordered Silvadene cream to the burned area.

In a telephone interview on 1/26/2023 at 10:14 AM, Physican #2 verified she was working in the ED on 12/4/2022 and was on call for the med surge floor. Physican #2 stated RN #2 informed her a patient had a burn from some type of heat bottle or pad. Physican #2 stated she gave a verbal order for Silvadene cream to be applied to the area as the on call physican. Physican # 2 stated she did not examine Patient #1 because the ED was very busy on the night of 12/4/2022.

In an interview on 1/25/2023 at 10:25 AM, RN #3 verified she was a former floor nurse, but was now the case manager and her primary duties were discharge planning and she no longer worked as a floor nurse. When asked if she had demonstrated to PCT #1 how to use the ice pack as a heat pack by putting water from the coffee pot into the ice pack, she stated, "...Not sure if I showed her [PCT #1] how...I have done that many years...I would always use cold water to cool it down..." RN #3 stated she would fill the pack partially with water from the coffee pot spicket and add cold water to dilute the heat.

The hospital governing body failed to ensure nursing staff followed approved polices and procedures to obtain a physician order for heat therapy, failed to implement a hospital approved method for heat therapy, which resulted in harm to Patient #1 in the form of a severe burn. Due to the hospital acquired burn, Patient #1 was required to receive pain mediations and antibiotics to prevent infection of the burn, dressing changes, treatments and debridements to the burn.