Failure to Assess and Implement Safety Measures for Hot Liquids and Fall Prevention
Penalty
Summary
A resident with severe cognitive impairment, upper extremity weakness, and a history of falls was not comprehensively assessed for safety with hot liquids, nor were appropriate interventions implemented to prevent burns. The resident required staff assistance with activities of daily living and had an occupational therapy plan indicating upper extremity weakness and a need for set-up or clean-up help for eating. Despite these needs, there was no assessment or care plan addressing the resident's ability to safely consume hot liquids, and no interventions were in place to reduce the risk of burns from hot beverages. On the day of the incident, the resident was provided hot tea in a Styrofoam cup without a lid by therapy staff, using water from a hot water dispenser that was not temperature-monitored and dispensed water at 176 degrees Fahrenheit. The resident attempted to balance the cup on her lap, resulting in the hot liquid spilling onto her left thigh and causing large second-degree burns. Immediate first aid was provided, and the resident required ongoing pain management and wound care. Interviews confirmed that the facility's policy required evaluation of residents for hot liquid safety and the use of lids on hot beverages, but these measures were not followed in this case. Additionally, the resident had a care plan and physician's order for the use of Dycem in her wheelchair as a fall prevention intervention, but this intervention was not in place at the time of observation. Staff interviews and observations confirmed that the Dycem was not present in the resident's wheelchair, despite being ordered and care planned. The lack of adherence to both hot liquid safety protocols and fall prevention interventions contributed to the resident experiencing actual harm.