Failure to Prevent Elopement and Hot Liquid Burn Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who was moderately cognitively impaired and assessed at medium risk for elopement, was able to leave the facility in his wheelchair without staff knowledge. The resident was found outside the facility at a nearby intersection, having been let out by a family member of another resident who had access to the door code. The door alarm did not sound, and staff were unaware of the resident's absence until he was returned by a nurse who happened to see him outside. The resident had no prior history of exit-seeking behavior, and the care plan required supervision while smoking but did not anticipate this type of elopement. Another resident, also moderately cognitively impaired and with limited mobility, sustained a second-degree burn after spilling hot coffee on herself. The resident had requested her coffee be reheated, and a CNA used the microwave to heat the beverage before returning it to the resident, who was lying with her bed head lowered. The CNA placed the coffee on the overbed table and left the room after warning the resident that it was hot. The resident attempted to drink the coffee without raising her head, resulting in the spill and subsequent burn to her chin and chest. The resident had difficulty grasping the cup due to weakness in her left hand and was right-handed but wore a wrist splint on her right wrist. In both cases, the facility did not implement or enforce adequate supervision or safety measures to prevent the incidents. The first resident was able to exit the building due to a lack of control over access codes and insufficient monitoring of visitors' actions. The second resident was given a hot beverage without proper assessment of her ability to safely consume it in her current position, and the staff member did not ensure the resident was sitting up before leaving the coffee within reach.