Failure to Supervise Resident Handling Hot Beverage Resulting in Burn
Penalty
Summary
The facility failed to provide adequate supervision to a resident with moderately impaired cognition and poor safety awareness while handling a hot beverage. The resident, who has a history of chronic medical conditions including COPD, seizures, TIA, cerebral infarction, and unspecified dementia, was given coffee by kitchen staff in an open cup without a lid. The resident, who is dependent on a wheelchair for mobility and requires assistance with transfers and mobility, attempted to self-propel his wheelchair while holding the cup. This resulted in the resident spilling the hot coffee onto his lap, causing burns to his right thigh and knee. Staff interviews confirmed that the resident was frequently seen with coffee and that staff were aware of his impaired safety awareness and cognition. Prior to the incident, the facility did not have a policy regarding the use and supervision of hot beverages. The care plan for the resident did not include interventions such as providing a cup with a lid or staff assistance when handling hot beverages. Multiple staff members, including the CNA, LPN, and DON, expressed concerns about the resident's ability to safely handle hot beverages, noting that he often tilted his cup in his lap while moving in his wheelchair. The lack of a hot beverage policy and failure to implement appropriate supervision or safety measures directly contributed to the resident sustaining a second-degree burn.