Failure to Prevent and Investigate Recurrent Resident Burns from Hot Beverages
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and poor safety awareness, resulting in two separate burn incidents from hot beverages. The first incident occurred when the resident spilled hot chocolate on their thigh, which was not reported to staff until the following day. Documentation shows that the only intervention after this incident was resident education, and there was no thorough investigation or root cause analysis conducted to determine how the accident occurred or to prevent recurrence. The care plan was updated to address wound care but did not include specific interventions for hot beverage safety or increased supervision. A second burn incident occurred several months later when the same resident sustained second-degree burns after placing a hot cup of coffee next to their thigh while self-propelling in a wheelchair. Again, the facility did not conduct a root cause analysis or a comprehensive investigation to determine if the accident was avoidable. The only new interventions at the time were the provision of a lidded coffee mug and cupholder, but these were not promptly added to the resident's care plan or communicated to all relevant staff. The care plan update focused on wound care and supervision during meals but did not address burn prevention or hot beverage management until much later. Both burn incidents were not reported to the New York State Department of Health as required. Interviews with facility staff, including the Administrator and Director of Nursing, revealed a lack of awareness regarding the need for a root cause analysis and timely reporting. There was also a delay in updating care plans and staff instructions to reflect necessary interventions for hot beverage safety, despite recommendations from the dietary team and discussions in morning reports.