**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively assess and develop interventions within the resident' environment to ensure safety and reduce the risk of avoidable injuries for 1 of 1 resident (R11) reviewed who demonstrated repeated behavior of placing their legs off the bedside and whose bed was placed next to an active heating element. These findings constituted an immediate jeopardy (IJ) situation, and substandard quality of care, for R11 when their feet were found directly on the heating element after an extended period of time resulting in multiple, full thickness burns and subsequent hospitalization. The IJ began on 12/13/23, when it was identified R11 had sustained multiple burns to their feet because their bed had been placed adjacent to an active, wall-mounted heating element. R11 had a known behavior of placing their feet off the bedside (i.e., in attempt to get up or reposition) which had not been reported by direct care staff to the nursing leadership team and, subsequently, was not acted upon or assessed to ensure safety within the environment given R11's bed placement near an active heating element. R11's feet were subsequently found directly touching the heating element which resulted in multiple, full thickness burns and subsequent hospitalization. The campus administrator and director of nursing (DON) were notified of the IJ for R11 on 12/14/23 at 2:38 p.m. The IJ was removed on 12/14/23, when an accepted removal plan was successfully implemented; however, non-compliance remained at an isolated scope with potential for more than minimal harm that is not immediate jeopardy (Level D). Findings include: A National Library of Medicine, National Institute of Health (NIH) Burn Classification article, dated 9/2023, identified burns can occur when skin is exposed to heat sources such as flames, hot objects, and electricity, with a patient's clinical comorbidities being able to influence the clinical outcome of such sustained burn(s). The article provided several classifications, and subsequent treatment options, for various burns which could be sustained. This included a section labeled, Full-Thickness Burns, which outlined, A third-degree burn, also known as a full-thickness burn, is more severe and affects the epidermis and dermis skin layers . These burns result in a leathery, stiff, and dry appearance . the affected area does not blanch under pressure due to compromised blood supply . nerves at this depth are also damaged, resulting in the patient experiencing no sensation or pain . burns [like these] take more than 8 weeks to heal . Further, a Antiscald Burn Exposure Chart, dated 2016, identified a chart with various temperature' skin exposure time to receive a severe burn. This outlined a 120 degree (F) temperature could cause a 2nd degree burn at eight (8) minutes and a 3rd degree burn at 10 minutes time. A facility' submitted incident report (FRI), dated 12/13/23, identified an allegation of neglect for R11. The FRI identified R11 had been transported to the hospital (i.e., Hennepin County Medical Center [HCMC]) and outlined, On the last rounds of night shift . [R11] was noted to have feet off the edge of her bed and on the heater in her room . toe and foot noted to have a burn. First aid was applied . order given to send resident to HCMC ER [emergency room] for further evaluation. R11's quarterly Minimum Data Set (MDS), dated [DATE], identified R11 had severe cognitive impairment, required extensive assistance with transfers and bed mobility, and had several medical conditions including diabetes mellitus and Alzheimer's Disease. Further, the MDS outlined R11 had no current wounds or burns present on their skin. R11's most recent Fall Risk (Acuity) and Functional Limitation ROM (range of motion) evaluation, dated 10/3/23, identified R11 demonstrated intermittent confusion and safety awareness; and was listed as having impaired hearing or vision, neuromuscular limitations (i.e., loss of limb movement, decline in functional status), and cognitive conditions (i.e., Alzheimer's). These factors considered, R11 was determined to be at high risk for falls with an assigned score of, 16.0000. The evaluation continued and outlined R11 had no ROM limitations on their lower extremities which placed them at risk of injury. The evaluation concluded with a radio-button answered, Continue Current Plan of Care. However, the completed evaluation lacked any evidence R11's immediate environment (i.e., bedroom), or subsequent hazards within, had been evaluated to determine what, if any, risks were present which could place R11 at risk of injury (i.e., falls, burns). On 12/13/23 at 1:22 p.m., R11's room was observed. The room was a double-bed room (i.e., shared room) and was located at the end of a hallway in the long-term care unit. The room opened from a single door into a space which was separated down the middle using a privacy curtain, and R11's bed was positioned against the wall adjacent to the window. The wall adjacent had a large picture window with an off-white-colored heater vent below near the floor which extended across the room. The cover was on with a visible dent in the register at this time, and the unit was not hot to touch. Further, the room had several signs posted which read, CALL Don't Fall, but no other visible safety instructions posted (i.e., keep bed away from heater). R11 was not present at this time (i.e., hospitalized ). R11's progress note, dated 12/10/23, identified R11 had a shower completed and nursing identified, . scabs on 2 toes on the right foot and some red areas on top of both feet. Appears to be from her shoes. The note lacked any evidence R11 had multiple burns or areas of black, discolored skin present on her feet. However, R11's electronic medical record (EMR) Wound Management section, printed 12/14/23, outlined R11 had no active or healed wounds or skin issues on their body with dictation, There were no wounds that match your search criteria. Further, the entire medical record was reviewed and lacked evidence R11 had any burn or burn-type injuries present prior to 12/13/23. When interviewed on 12/13/23 at 1:46 p.m., nursing assistant (NA)-E stated they had worked with R11 multiple times prior and described R11 as needing pretty much total assist with most cares adding R11 was not with it cognitively. NA-E stated they were aware of the incident with R11 on 12/13/23, as they had just arrived to work the day shift after it happened when the nurse voiced something happened. NA-E stated they walked into R11's room and saw staff members present taking photographs of R11's feet who voiced they found her feet on the heater pipe along the bottom of the wall. NA-E stated R11 used a high-low bed for safety as she often tried to get up from bed on her own and staff would find her with her legs outside of the bed on a daily basis almost. At 1:50 p.m., NA-E observed R11's room with the surveyor present. NA-E verified the bed was now moved to the opposite wall from where it had been when the incident happened adding R11's bed used to be kept parallel with the wall which had the window and heating element present. When the incident happened on 12/13/23, NA-E verified R11's leg had been found touching the heating element while the bed was in low position. NA-E stated the bed was, typically, only kept like a foot away from the wall and heating element in the past from their observations. NA-E stated they had never been told or directed to monitor R11's bed placement or ensure it was kept a certain distance from the wall prior to the incident on 12/13/23, and added such action was not the responsibility of the nursing staff but rather this was maintenance' responsibility. NA-E reiterated R11 did, at times, place her legs over the bedside in attempt to get up and, as a result, the staff try to get her up quickly in the mornings to prevent falls. However, NA-E added they don't know if the nurses' were aware of it or not adding they had never reported it to anyone as they were typically doing TMA (trained medication aide) work instead. NA-E explained some other rooms had wooden brackets or markings installed on the beds to prevent them from contacting the wall but R11's bed did not have anything like such installed to their recall. NA-E then walked the surveyor to the room located across the hallway from R11's room and showed the bed which had a visible wooden bracket installed along the bottom which prevented the bed frame from touching the wall. NA-E stated R11's bed now moved to the opposite wall, and away from the heating element, was the best idea to help prevent more burns on the heating element; however, reiterated there had been no direction or instructions to check R11's bed placement for safety despite being placed next to a heating element prior to the incident on 12/13/23. When interviewed on 12/14/23 at 6:03 a.m., NA-F stated they typically worked on the night shift and verified they were the NA assigned to care for R11 on 12/13/23, when the incident happened resulting in R11 being burned. NA-F explained they had worked with R11 multiple times in the past and described her as pretty much a check and change during the overnight hours adding R11's bed was usually kept in the down (i.e., low) position due to her risk for falls. NA-F stated R11 was physically capable of rolling side to side while in bed and, at times, would swing her legs off the bedside while repositioning herself or if attempting to get up for some reason adding they had observed a couple of times when R11 would be found with her legs off the bed on the window side (i.e., next to the heating element). NA-F stated R11 was not on any formal safety checks (i.e., her position in bed or bed position in room) while in bed during the overnight hours but rather just on the routine rounds (i.e., every 2-3 hours) all patients were on. NA-F stated they believed the nurses were aware of R11's behavior of placing her legs and feet off the bedside as that's why the bed have [has] to be lower all the time, and expressed staff just put her feet back into bed when found in such manner. At 6:07 a.m., NA-F observed R11's room with the surveyor present and verified the bed had been moved to the adjacent wall since the incident happened. NA-F explained R11's bed had been positioned parallel with the wall which had the window and, directly below that, the heating element which ran the length of the room. NA-F stated R11's bed, while in the low position, was usually only kept about 10 inches or so from the wall and heating element while using their hands to show the physical space. NA-F recalled the incident on 12/13/23 and explained they had been doing last rounds for the shift and were behind schedule due to being the only NA working. NA-F entered the room and found R11 lying in bed on her left side facing the window and covered with blankets. NA-F stated R11 had not been crying or making any noise when they entered the room, however, upon removing R11's blankets then saw the blood[like] substance dried to her feet which were directly touching the heating element. NA-F stated they could see areas on the skin (i.e., burns) which had not been there on the prior rounds and, as a result, called for the nurse to come down and check on R11. NA-F stated the skin impairments were cause of the heat from the heating element and described them as smooth, discolored, and shiny areas. NA-F stated they had never been told or directed to check the bed position, in proximity to the heating element, prior to the incident on 12/13/23. However, R11's medical record was reviewed and lacked evidence this behavior had been comprehensively assessed to determine what, if any, safety interventions needed to be placed to promote a safe environment with R11's bed kept near an active heating element. In addition, R11's care plan, last revised 10/9/23, identified R11 had a communication deficit and directed staff to, Anticipate my needs. The care plan outlined R11 had a self-care deficit, required assist of one with bed mobility, and had socially inappropriate or disruptive behavioral symptoms due to hearing loss evidenced by, at times, yelling out for her family member. The care plan identified R11 was at risk for falls due to impaired mobility and Alzheimer's Disease and directed to ensure R11's bed was kept in a low position when in use. However, the care plan lacked evidence R11 had any behaviors or patterns of placing her feet or legs off the bedside, nor any subsequent interventions to address such including interventions to ensure safety within her environment, despite direct care staff members witnessing this behavior multiple times prior to 12/13/23. On 12/14/23 at 6:15 a.m., licensed practical nurse (LPN)-A was interviewed and verified they were the nurse who had been working when R11 had sustained the burns on 12/13/23. LPN-A explained R11's room was the last one down the hallway and, to their knowledge, she had typically slept well during the overnight hours. LPN-A stated R11 was a fall risk and, at times, would try to get up from bed so, as a result, they tried to keep her bed in the low-position when occupied. LPN-A recalled the incident from 12/13/23 and explained they had been in R11's room between 4:45 a.m. and 5:00 a.m. to give R11's roommate some medication. At that time, R11 appeared to be sleeping in bed on her left side facing the window. LPN-A stated R11 seemed comfortable, however, verified they did not physically move any of the bedding to check her adding they didn't see or smell anything of concern. LPN-A then left the room and finished the early morning medication pass until later when the NA came down and reported R11 had something on her leg and needed to be seen. LPN-A stated they entered the room and there was a little blood on R11's feet and the wall adding, upon inspection, her feet had black spots on the skin and toes which had not been there prior. The charge nurse was notified and responded who then measured the areas and took photographs of them. LPN-A verified R11's bed was in the low position and parallel with the heating element when they responded to the NA' request adding R11 had not ever been on any formal safety checks while in bed (i.e., placement away from heater) to their knowledge. LPN-A stated now, since the incident, staff were going around to all the rooms and checking bed placement to ensure none are kept too close to the heating elements adding burns from them had never happened before to their knowledge. LPN-A explained they were aware R11 was able to turn herself back-and-forth (i.e., side to side) in bed, however, they were unsure what, if any, interventions were done for that or to ensure safety within R11's environment as a result adding any evaluations of such would be the care managers' responsibility to do. LPN-A added, Check with the manager. R11's progress note, dated 12/13/23 at 7:10 a.m. (recorded as late entry), identified LPN-A was notified by the nursing assistant (NA) to come and check R11. The note outlined, Burn wounds were noted on the L [left] leg/foot and some burns also on R [right] foot. The charge nurse was notified . took some measurement. On call provider [named] was called and updated . gave orders to send patient to ER . paramedics were called and they came and transported resident to HCMC . R11's subsequent progress note, dated 12/13/23 at 7:19 a.m., identified registered nurse unit manager (RN)-A recorded, Resident was observed having burn wounds on bilateral feet. Left outer great toe, 2.5 cm [centimeters] X 1.5 cm undetermined depth wound bed black not bleeding. Left outer foot outer aspect just below 5th digit, 4 cm X 4 cm undetermined depth wound bed black not bleeding . Right foot inner aspect 2.5 cm X 2 cm undetermined depth wound bed black not bleeding . did not have any S&S [signs and symptoms] of discomfort at the time . has Alzheimer's/dementia and DM2 [diabetes] . Unable to verbalize how the burns happened . has decreased safety and space awareness . left around 6:50 [a.m.] on a stretcher accompanied with paramedics. A corresponding Skin Integrity Events -- Burn Event, dated 12/13/23, identified R11 had sustained burns of feet and listed the same measurements as the recorded progress note. A section labeled, Etiology of Burn, identified these as, Contact Burn: Hot surface ., and listed a classification of them as, Full Thickness . The event report outlined R11 was sent to the ED and R11's physician was notified of the incident. R11's Hennepin Healthcare ED Triage Note, dated 12/13/23 at 7:29 a.m., identified R11 was brought in via ambulance from the care center. The note outlined, Staff found her this morning with her feet over the edge of the bed between bed/wall and feet resting on the baseboard heater. Sustaining Full thickness burn to bilateral feet - worse on left. R11's corresponding ED Provider Note, dated 12/13/23, identified R11 presented to the ED with . severe burns to the bilateral feet. R11 was recorded as having Alzheimer's Disease and was unable to provide any history when asked. The note outlined, Apparently she was attempting to move out of her bed and her feet were placed on a heater. They were placed there for multiple hours. She does not have apparent pain, however likely due to her diabetes. The burn team was consulted and recommended outpatient follow-up, however, due to family concerns for safety, R11 was admitted to the hospital adding, There were concerns for elder abuse as the burns did not match the history given from the nursing home. R11's subsequent Hospitalist admission - Staff note, dated 12/14/23, identified a section labeled, Assessment, which outlined, 3rd Degree Burns to Right and Left Feet ., with no surgical intervention being required. The note outlined the burns were being treated with proper hygiene, dressing changes, and silver sulfadiazine (a topical antibiotic used with burns to prevent infection) and included several photographs of the resulted burns. When interviewed on 12/13/23 at 8:07 a.m., the environmental services director (ESD) explained they had been notified via telephone of the incident with R11 on 12/13/23. ESD explained the heating element inside R11's room, positioned underneath the window, was a glycol and water mixture which passed through a tube and radiated heat from the wall-mounted unit. ESD stated when the zone valve calls for heat (i.e., activated) then the unit can get warm, adding the maintenance staff did check surface temperatures of these heating elements; however, they were not routinely documented. ESD stated the water inside the heating element was approximately 168 degrees (F) when it left the boiler and, by the time it reached the room or element, was likely in the 138-141F range with a unit' surface temperature of about 120 [F]. ESD explained R11's bed had been the only one which, to their knowledge, had been positioned near a heater like that due to family preference. ESD stated none of the staff had ever reported any potential safety concerns to him with the bed' position, however, explained just two weeks prior the maintenance department had been called to replace the heating element cover which had been displaced due to the high-low bed tearing it from the wall (i.e., due to being placed so close) when it was being either raised or lowered. When asked if that had been reported as a possible safety issue, ESD stated resident' bed placement within the room was not maintenance' responsibility but rather they just checked to ensure the bed worked correctly adding, [We're] not one to tell how they [nursing or resident] orient the room. ESD verified they had never been asked to mark R11's room, bed or floor with any safety markings or instructions (i.e., keep bed away from heater) prior to the incident on 12/13/23, and reiterated nobody had presented any potential safety concerns to their department with the bed being placed close to the heater despite R11 having a known behavior of placing her legs over the side. A corresponding Work Order #9715, undated, outlined a header which read, Heater Cover, and listed R11's room number. The work order had been requested by the nursing department with notes which read, Heat cover to base board heater has been damaged and needs to be repaired. A due date was listed which read, Dec. 13, 2023. A subsequent section labeled, Comments, outlined, Straighten out the cover and reattached cover to base boards. The completed work order lacked evidence the room or immediate placement of R11's bed had been evaluated for safety given the proximity to the heating element and the bed physically damaging the cover. On 12/14/23 at 9:58 a.m., the director of nursing (DON) and RN-A were interviewed. DON explained they had just returned from a leave of absence the week prior, and RN-A stated they had just started working at the nursing home about three weeks prior. DON verified they had reviewed R11's medical record and described R11 as having severe cognitive impairment and diabetes mellitus and who required extensive assist with most cares. However, DON and RN-A both expressed they were unaware the direct care staff had observed, multiple times, R11 to place her legs off the bedside in attempts to either reposition or get up adding, Not that I am [was] aware of. DON stated they believed R11 needed assistance with bed mobility as had been reflected in the NA charting on a consistent basis, and RN-A expressed if staff had witnessed behaviors such as those they should have been reported to the nurses or directly to me so it could be reviewed and addressed by the interdisciplinary team (IDT) for intervention. RN-A verified they had seen R11's injuries on the morning of the incident and stated the heating element caused three sites of burn with two of them being black and discolored adding R11 did not, to their knowledge, have any skin issues on their feet prior to these burns. DON reviewed R11's medical record and care plan, and they verified it lacked evidence the identified behavior had been evaluated or acted upon to review what, if any, safety interventions were needed to keep R11 safe while in bed with the bed positioned next to an active heating element and her displaying repeated behaviors of placing her feet outside of the bed and over the edge. RN-A stated if they had been told of such behavior, they would have evaluated R11 for potential risks and included therapy (i.e., PT, OT) to screen her for bed mobility and any needed safety interventions, then care planned those for staff awareness and guidance. DON stated R11's bed was kept parallel to the window at family request due to television placement and viewing in the room, however, expressed such knowledge was just hearsay after the incident with nothing about room layout being care planned. DON verified R11 was not on any specialized safety rounding or formal safety checks (i.e., safe in environment) while in bed prior to the incident and expressed the facility had just audited the other resident rooms with R11's bed being the only one found to be placed in close proximity to the wall-mounted heating elements. DON explained, since the incident on 12/13/23, they were working to verbally educate staff on bed placement but verified a resident' bed should not be kept near an active heating source to help reduce the risk of burns or fire. When interviewed on 12/14/23 at 1:24 p.m., the campus administrator explained they had started to begin education with all staff on resident' safety with the heating elements. The administrator stated they expected resident' beds to be kept an appropriate distance from the wall-mounted elements and nothing should be placed next to or on the heaters. However, not all staff had been educated yet. The administrator stated they were also going to develop and review a four-point quality project to help them better identify the root cause of the incident and what, if any, actions needed to be done. The written education with staff, thus far, was provided and reviewed. This included a single page titled, Resident Bed Proximity to Room Heater, and included a photograph of the type of heating element which had caused the burns to R11 on 12/13/23. The education included several statements which directed, Staff to ensure resident beds are an appropriate distance (at least 3 feet) aware from heaters in resident room during all rounding and resident interactions, and, No items can be on a heater. If personal items or items of any kind are on heater, please educate the resident on the need to remove them due to a safety risk. There were several attached signature pages which had various staff' signatures, however, the provided education lacked evidence the facility had identified or started education on ensuring resident' behaviors, such as placing feet off the bedside, are promptly reported and acted upon to ensure safety within the environment. A provided Change in Condition policy, undated, outlined a procedure which included, Assess significant change in the resident's condition noted through direct observation, interview or report from other staff. The policy directed to notify the resident' physician and . appropriate members of the IDT team, and, Update the care plan as appropriate. A facility' policy on resident safety within the environment was requested, however, none was received. The IJ which began on 12/13/23 was removed on 12/14/23, when the facility successfully implemented a removal plan which included evaluating all resident' rooms with heating elements to ensure appropriate bed placement away from the devices, completing a root-cause analysis of the incident to help better determine what, if any, interventions or education was needed to prevent recurrence, and educating staff members on how to identify and report potential behaviors or resident' changes to ensure their evaluated to reduce safety hazards within the environment and associated resident harm. These interventions were verified as having been implemented on 12/15/23 evidenced by a review of available documentation and multiple interviews with various staff members who verified education had been completed as outlined.