Failure to Implement Hot Liquid Safety Policy Results in Resident Burn
Penalty
Summary
A resident with a history of dementia, metabolic encephalopathy, diabetes mellitus type 2, and falls, who was on hospice care, sustained a second-degree burn after spilling hot coffee on himself. The facility failed to implement its hot liquid policy and did not accurately assess or provide adequate supervision for the resident, despite the resident's documented poor hand control and moderate to severe vision impairment. The resident's hot food/liquid assessment indicated high risk, but only a cup with a lid was recommended, and no other safety interventions were put in place. On the day of the incident, the Assistant Director of Nursing provided the resident with coffee, which was poured from a pot and prepared with cream and sweetener, then given to the resident with a lid. The staff member left to get coffee for another resident, during which time the resident spilled the coffee, resulting in burns to the inner thigh. Initial care involved applying a cold washcloth and later Silvadene cream, but there was no evidence of a wound assessment or additional treatment orders in the medical record. Subsequent documentation confirmed the presence of partial-thickness burns with blisters and open areas. Interviews and observations revealed that staff were not consistently aware of or following the facility's hot liquid temperature policy, with coffee temperatures exceeding the policy limit. Staff also lacked clarity on supervision requirements and the use of special equipment for high-risk residents. The Director of Nursing was unable to provide incident or accident reports for the burn and could not explain discrepancies in the resident's assessment documentation. Additionally, other residents had not been evaluated for hot liquid safety prior to being served, and staff were not consistently monitoring or documenting hot liquid temperatures as required.