Resident Burn from Hot Coffee Despite Safety Interventions
Penalty
Summary
A resident with diagnoses including Parkinsonism, dementia, and dysphagia, and assessed to have impaired cognition, sustained a burn after spilling hot coffee on himself during lunch. At the time of the incident, the resident was using a two-handled cup with a spouted lid as recommended by Occupational Therapy to prevent spillage and burns. Despite these interventions, the resident spilled coffee, resulting in a blister and redness on the right outer leg, later assessed as a second-degree burn measuring 10.5 cm by 6.6 cm. Record review and staff interview confirmed that all safety interventions and the plan of care were in place and functional at the time of the occurrence. The incident was documented in nursing progress notes, and the burn was assessed and measured by the facility. The event affected one resident out of three reviewed for accidents, and the facility census was 93 at the time.