Failure to Assess and Supervise Resident Handling of Hot Liquids Resulting in Burn Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and mobility issues sustained a second-degree burn after spilling hot water on her leg. The incident happened when the resident, who had diagnoses including unspecified dementia and arthritis, accessed a hot water dispenser and spilled 180°F water onto her lap, resulting in burns to her left thigh. The resident reported the incident to staff, and subsequent assessment confirmed the injury. Review of facility records and interviews revealed that there was no documented assessment of the resident's ability to safely handle hot liquids, despite the facility's policy requiring such evaluations. The policy also outlined specific interventions and precautions for residents with difficulties handling hot beverages, such as the use of assistive devices, supervision, and individualized care planning. However, the resident's care plan did not reflect any hot liquid safety assessment or related interventions. Staff interviews indicated that while in-service training on hot beverage safety and abuse prevention had been provided, the Director of Nursing (DON) was unaware of any formal hot liquid assessment being implemented. Staff relied on general knowledge and resident diagnoses to determine safety measures, rather than a structured assessment process. This lack of individualized assessment and care planning contributed to the resident's exposure to an accident hazard, resulting in injury.