Failure to Supervise and Ensure Safe Beverage Temperature Results in Resident Burn
Penalty
Summary
A deficiency occurred when staff failed to check the temperature of a hot beverage before serving it and did not provide necessary assistance and supervision to a resident who was dependent on staff for eating and drinking. The resident, who had severe cognitive impairment, multiple physical and mental health diagnoses, and was on hospice care, was known to require full assistance with eating and drinking, as documented in her care plan and Minimum Data Set (MDS) assessment. Despite these documented needs, the resident was given a hot chocolate that had not been temperature-checked and was left unsupervised, resulting in her spilling the beverage on herself. The incident led to the resident sustaining second-degree burns on her left hip and thigh, which caused her pain and required ongoing wound care and pain management. Interviews and records revealed that the hot chocolate was prepared in the kitchen, placed in a cup without a lid, and delivered to the resident without verifying the temperature or ensuring staff were present to assist. Staff statements confirmed that the resident typically sat at a table where assistance was provided during meals, but at the time of the incident, it was not mealtime and no staff were present to help her with the drink. The facility did not have a hot liquid risk assessment in place for the resident, and there was no documentation of hot beverage temperatures being checked or logged. The facility's policies required that residents who are unable to feed themselves be fed with attention to safety, comfort, and dignity, and that staff be trained to identify and prevent accident hazards. However, these protocols were not followed in this case. The lack of supervision and failure to check the temperature of the hot beverage directly resulted in the resident's injury, as confirmed by multiple staff interviews and medical documentation.