Failure to Prevent Accidents Due to Unsafe Hot Liquid Handling and Omission of Gait Belt Use
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent avoidable accidents for two residents. In one incident, a resident sustained a burn injury to her right leg after spilling hot broth that had been improperly prepared by a new cook who did not follow the facility's established procedures for safe food preparation and service. The cook used water from a stovetop kettle instead of the coffee machine, which is calibrated to maintain a safer temperature, and did not check the temperature of the broth before it was delivered to the resident's room. The resident, who had a history of left hip fracture, transient ischemic attack, macular degeneration, and tremor, was found with redness and later a blistered area on her right thigh after the spill. In a separate incident, another resident fell while being assisted back from the bathroom by a CNA who failed to use a gait belt, contrary to the resident's care plan and facility policy. The resident, who had a history of osteoporosis, multiple lumbar compression fractures, and moderate cognitive impairment, was identified as being at risk for falls and required assistance with transfers and ambulation using a front-wheeled walker and a gait belt. During the incident, the CNA applied the resident's TLSO brace but did not use a gait belt, and the resident was guided to the floor after reporting weakness in her knees. The resident sustained skin tears during the assisted fall. Both incidents involved staff not adhering to established facility policies and procedures designed to prevent accidents and injuries. The first incident resulted from a failure to follow safe food handling protocols for hot liquids, while the second incident was due to the omission of a required safety device during resident transfer. These actions directly contributed to the residents' injuries and represented a failure to maintain a safe environment as required by facility policy.