Failure to Monitor Hot Beverage Temperature Results in Resident Burns
Penalty
Summary
A resident with diagnoses including spastic paraplegia, demyelinating disease of the central nervous system, hypertrophic osteoarthropathy, cerebellar ataxia, lack of coordination, and muscle spasm, who required setup assistance for eating due to limited mobility, requested a CNA to heat a cup of water. The CNA heated the water in a microwave and placed it on the resident's bedside table without monitoring or checking the temperature of the water. When the resident raised the head of her bed, the cup of hot water was knocked over, spilling onto her abdomen, back, and hip. As a result of the spill, the resident sustained second-degree burns to her abdomen, lower back, and left hip. The burns were described as partial thickness with large blisters, reddened areas, and peeling of the outer skin layer. Wound assessments documented significant areas of injury, with pain rated at 4 to 5 on a scale of 0 to 10. The resident required topical treatments and dressings for the burns, and the incident was reported to the physician, who ordered further care and assessment. The facility's policy required staff to monitor, serve, and hold hot beverages in a safe manner, including checking temperatures and monitoring high-risk residents. However, there was no documentation or indication that the temperature of the water served to the resident was checked, and the staff did not monitor the resident while serving the hot beverage. This failure to follow established procedures for serving hot beverages directly contributed to the resident's injuries.