Failure to Prevent Accident Hazards: Hot Liquid Burns and Chemical Ingestion
Penalty
Summary
A deficiency was identified when a resident with severely impaired cognition and a history of dementia, delusional disorders, and lack of coordination sustained burn injuries to both thighs after spilling hot coffee on themselves. The resident required supervision for eating and was observed to have shaky hands while feeding. Coffee was served at temperatures exceeding 150 degrees Fahrenheit, with staff and surveyors noting that the beverage was very hot and could cause burns. There was no consistent documentation that all staff had been in-serviced on safe coffee temperatures, and staff interviews revealed uncertainty about proper procedures for checking beverage temperatures before serving. Another deficiency occurred when a resident with severe cognitive impairment, intellectual disability, and a history of aspiration pneumonitis ingested Pine-Sol that had been left in a Styrofoam cup on a housekeeping cart. The resident required supervision for eating and was able to access the chemical, mistaking it for coffee. Following ingestion, the resident experienced vomiting, respiratory distress, and was subsequently hospitalized with acute respiratory failure and aspiration pneumonitis. Staff interviews indicated that chemicals were supposed to be locked and labeled, but the incident demonstrated a failure to secure hazardous substances. Both incidents involved residents with significant cognitive impairments who required supervision and were exposed to preventable hazards due to lapses in staff adherence to safety protocols. The facility failed to ensure that hot beverages were served at safe temperatures and that chemicals were properly secured, resulting in harm to the residents involved.