Failure to Provide Supervision and Hot Liquid Safety Results in Resident Burn
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for one resident, resulting in harm. The resident, who had multiple diagnoses including respiratory failure, traumatic brain injury, communication deficit, repeated falls, and required physical assistance with eating, was served hot soup measured at 170 degrees Fahrenheit. The resident's care plan and physician orders specified that hot liquids should be served with lids and that the resident required supervision and assistance during meals. However, these interventions were not followed, and the resident was left unsupervised with uncovered hot soup, which he subsequently spilled onto his right upper, inner thigh, causing a second-degree burn. Staff interviews and documentation confirmed that the dietary and care plans indicated the need for lids on hot liquids and staff assistance, but these were not implemented at the time of the incident. The DON acknowledged that the resident should have had a lid on the soup and required assistance during meals, which was not provided. As a result, the resident suffered a burn injury that required treatment, demonstrating a failure to follow established safety protocols and care plan interventions.