The report goes on to state that the Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The resident had neuropathy (nerve damage) from a previous stroke that affected feeling in his feet. The facility failed to assess the resident for foot soak.treatments, failed to obtain provider orders, failed to update the plan of care to include foot soaks, and failed to train staff specifically on how to provide the resident foot soaks. In addition, the facility failed to update the resident’s provider the day the foot burn injury occurred and the following day when the resident’s foot burn worsened.

The resident sustained a partial thickness burn of his left foot and required hospitalization.

The report goes on to state that during an interview, a nurse stated she was aware staff provided the resident foot soaks for comfort due to pain from his nerve damage. The nurse stated the day of the incident, the AP provided the resident a foot soak and the AP said she checked the water temperature while wearing a surgical glove. At some point during the soak, the resident felt warmth, and eventually took his foot out of the water.

Both the AP and resident noticed a burn injury and the AP reported the injury to the nurse. The nurse stated she arrived at the facility within an hour and the resident’s skin was red, swollen, intact, with no fluid filled blisters at that time. The nurse stated she cleaned the burn injury with rubbing alcohol and had the resident elevate his leg/foot. The nurse stated the resident refused to go to the emergency room and the next day, when the wound worsened, with the blisters oozing, the resident continued to refuse an evaluation at the emergency room. The nurse stated on the second day, she dried the burned area with gauze, and had the resident elevate his foot. The nurse stated she did not speak directly to the resident’s provider regarding the resident’s burn the day of the burn and the following day when the burn worsened. The nurse stated she contacted the clinic the day of the incident to check for an earlier appointment time. The nurse stated she had not encountered a situation when a resident refused a hospital visit when she felt the resident needed to be seen for treatment. The nurse stated the AP, and all the other staff were trained on water safety for providing showers/baths however, staff did not receive training, demonstration, or competency on how to provide the resident’s foot soaks prior to the incident. The nurse stated the resident’s foot soaks were not assessed, or part of the resident care planned services.

In conclusion, the Minnesota Department of Health determined neglect was substantiated.