Failure to Follow Hot Beverage Policy Results in Resident Burns
Penalty
Summary
A deficiency occurred when the facility failed to ensure a safe environment and adequate supervision for a resident with moderate cognitive impairment, dementia, impaired vision, and a need for assistance with activities of daily living. The facility's hot beverage policy required that coffee and hot water be cooled to 130 degrees before serving to residents, and that only dietary staff provide hot beverages after checking the temperature. However, a staff member brought a personal coffee pot to the nursing station, and an LPN served hot coffee to the resident without checking its temperature, in violation of the policy. The resident, who had diagnoses including dementia, seizure disorder, and anxiety, requested coffee and a snack. The LPN provided the coffee, which the resident subsequently spilled on their chest and abdomen while unsupervised. The incident resulted in burns, with progress notes documenting reddened areas, blisters, and wounds to the chest and abdomen. The resident required wound care, including cleansing, application of antibiotic ointment, and dressings, as well as additional supplements and medications as ordered by the provider. Interviews and record reviews confirmed that the coffee pot was not authorized, the temperature of the coffee was not checked, and the resident was left unsupervised. Staff interviews revealed that the hot liquid policy was in place prior to the incident, but not followed. The resident's care plan and medical records indicated a need for supervision and assistance, which was not provided at the time of the incident, directly leading to the resident's injury.