Failure to Assess Hot Beverage Safety and Provide Timely Burn Care
Penalty
Summary
The facility failed to ensure that residents were evaluated for their ability to safely handle and consume hot beverages, as required by its own policies and procedures. Specifically, three residents were not assessed for hot liquid safety, including a resident with significant physical and cognitive impairments such as hemiplegia, hemiparesis, aphasia, and lack of capacity to make medical decisions. Despite the facility's policy mandating hot liquid safety evaluations upon admission, readmission, and change of condition, no such assessments were documented for these residents. An incident occurred in which the resident spilled hot tea onto her lap during lunch. Staff present at the time, including two restorative nursing assistants, did not immediately notify a licensed nurse or supervisor as required by facility policy. Instead, they patted the resident dry and allowed her to finish her dessert before informing a CNA, who later reported the incident to licensed nursing staff. The delay in notification resulted in a lack of prompt assessment and intervention for the burn injury. Following the incident, the resident developed blisters on her left upper thigh, which were not discovered until the following day during routine care. Documentation of the injury, physician notification, and appropriate treatment were not initiated until approximately 30 hours after the incident. The initial intervention included the application of ice to the burn, which is not recommended and can be harmful. There was no evidence that the resident's condition was promptly assessed, that a physician's order for burn treatment was obtained, or that the resident was properly monitored in the immediate aftermath of the incident.