Unsafe Hot Water Access and Inadequate Supervision Result in Resident Injury
Penalty
Summary
The facility failed to ensure safe water temperatures and adequate supervision to prevent accidents, resulting in serious harm to two residents. One resident, who had hemiplegia and cognitive impairment, was provided with hot water directly from a nurse's lounge auxiliary spout, which was measured at temperatures significantly above the safe limit of 120°F. The resident attempted to drink the water, spilled it on themselves, and sustained second-degree burns to the neck, chest, and abdomen. Staff interviews revealed that the hot water was routinely provided to this resident without checking or mixing the temperature, and staff were unaware of the actual temperature or the policy requirements. Another resident, with Alzheimer's disease and cognitive impairment, was observed entering the nurse's lounge unsupervised and accessing the same hot water auxiliary spout. This resident filled a metal container with hot water and resisted staff attempts to intervene, leaving the lounge with the hot water. Staff acknowledged that this resident had a history of entering nourishment areas to obtain hot water or use the microwave, often without supervision, and that residents were not permitted in the nurse's lounge. However, staff did not consistently prevent access or monitor the water temperature. Record reviews and staff interviews confirmed that the facility's policy required hot liquids to be served at safe temperatures, with water provided by dietary staff and not exceeding 120°F. Despite this, staff frequently used the nurse's lounge hot water spout, did not log or check temperatures, and were unaware of the risks. The lack of supervision and failure to adhere to safety protocols directly led to one resident's injury and placed another at risk of harm.
Removal Plan
- Remove the hot water auxiliary spout in the nurse's lounge
- Lock door to the nurse's lounge and require key access to nourishment rooms
- Provide training to staff
- Complete hot liquids evaluations for all residents
- Revise hot liquids safety policy