Description of Event or Problem · 1
SUMMARY OF OCCURRENCE: AT APPROX 1200 TODAY, RESIDENT WAS HEARD CALLING OUT. THE CHARGE NURSE IN THAT AREA HEARD THE RESIDENT, WENT DIRECTLY TO HER ROOM, AND FOUND THE RESIDENT SITTING IN HER LIFT CHAIR WITH FLAMES ABOUT HER CLOTHING ACROSS HER ABDOMEN. THE NURSE PUT THE FIRE OUT IMMEDIATELY AND THEN MADE SURE ANY SPARKS THAT HAD FALLEN TO THE FLOOR ABOUT THE RESIDENT'S CHAIR WERE EXTINGUISHED. THE AMBULANCE WAS CALLED AND THE RESIDENT WAS TAKEN TO THE EMERGENCY ROOM AT OUR HOSPITAL. THERE SHE WAS TREATED FOR BURNS AT THE ABDOMEN AND BETWEEN LEFT INDEX FINGER AND THUMB. SHE LATER RETURNED TO OUR FACILITY. BOTH AREAS WERE DETERMINED BY THE PHYSICIAN TO BE PARTIAL THICKNESS BURNS AND SILVADENE DRESSINGS WERE ORDERED FOR 7 DAYS. UPON FURTHER INVESTIGATION, WE FOUND THE CONTROL CORD ON THE RESIDENT'S LIFT CHAIR WAS BLACKENED AT THE JUNCTION OF THE HAND CONTROL DEVICE AND THE CORD CONNECTING TO THE HAND CONTROL DEVICE. ONCE EXAMINED, THE CHAIR WAS REMOVED FROM THE ROOM. THERE WAS MINIMAL SMOKE INVOLVED AND THE SMOKE DETECTOR DID NOT SET ALARM. THE ROOM WAS EASILY VENTILATED WITH OUTSIDE AIR. OUR MAINTENANCE STAFF AS PER OUR CURRENT POLICY HAS INSPECTED THE CHAIR ANNUALLY. THE RESIDENT WAS WEARING COTTON PANTS WITH AN ELASTIC WAISTBAND. SHE ALSO HAD ON A T-SHIRT THAT WAS TUCKED OVER THE DEPEND THAT WAS BURNT. OVER HER T-SHIRT SHE HAD A SWEATSHIRT TYPE JACKET THAT WAS NOT BURNT. ALSO, SHE HAD ON AN INCONTINENCE (DEPEND) PAD. THE FULL THICKNESS OF THE MATERIAL OF HER PANTS WAS BURNED, BUT THE WAISTBAND WAS INTACT. THE WAISTBAND OF THE T-SHIRT WAS SMOLDERING AND THE NURSE, UPON ENTERING THE ROOM, IMMEDIATELY EXTINGUISHED THAT. THE OUTSIDE PLASTIC ON THE DEPEND WAS BURNED AND THE INSIDE FILLING WAS SMOLDERING. THE SMOLDERING PIECES OF THE DEPEND WERE REMOVED IMMEDIATELY. THEN RESIDENT WAS TRANSFERRED TO THE HOSPITAL. ACTION PLAN: CONTINUE FURTHER INVESTIGATION OF THE INCIDENT. BASED ON RECOMMENDATIONS FROM THE STATE FIRE MARSHALL'S OFFICE, WILL INCREASE OUR MAINTENANCE CHECKS TO SEMI-ANNUALLY. CONTINUE TO MONITOR THE RESIDENT CLOSELY.