Failure to Complete Hot Liquids Risk Assessment for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary services in accordance with professional standards by not completing a Hot Liquids Risk Assessment for one resident with cognitive impairment and physical care needs. The resident, who had diagnoses including coronary artery disease, hypertension, and chronic pain, was noted to have short and long-term memory problems and required setup assistance for eating. Despite these needs, the resident was observed drinking coffee on multiple occasions, and a progress note documented that the resident spilled a cup of coffee, resulting in red blistering burns on both inner upper thighs. A review of assessments from January to June revealed that no Hot Liquids Risk Assessment had been completed for this resident, contrary to facility policy, which required such assessments upon admission and quarterly. Staff interviews confirmed a lack of awareness regarding the incident and the facility's policy on serving hot liquids. The Director of Nursing and Administrator both acknowledged that the required assessment was missing, and the facility's Hot Liquid Safety Policy was found to be incomplete regarding assessment procedures.