Resident Burned by Hot Food Due to Lack of Assessment and Supervision
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a need for supervision with activities of daily living was given a bowl of hot ramen noodles by a CNA, without an assessment of the resident's ability to safely handle hot liquids. The resident, who had diagnoses including bipolar disorder, difficulty walking, and weakness, received the hot noodles and was allowed to transport them on his lap down the hallway to his room. The resident subsequently spilled the hot noodles on his upper left thigh, resulting in a burn with a blister and surrounding redness. Facility policy required that reheated foods be cooled to a palatable temperature before consumption to prevent burns, and that all residents be assessed for their ability to handle hot liquids, with individualized care plans as needed. However, review of the clinical record showed no evidence that such an assessment had been completed for this resident prior to the incident. Staff interviews confirmed that no training had been provided on reheating food, taking food temperatures, or assessing residents' ability to handle hot liquids before the incident occurred. Multiple staff members, including CNAs, LPNs, RNs, and the Infection Preventionist, reported not having received training on reheating food or checking temperatures. The administrator and dietary manager also confirmed that residents had not been assessed for hot liquid safety prior to the incident. The lack of assessment and supervision directly led to the resident sustaining a burn injury from the hot noodles.