Failure to Prevent Resident Burns Due to Inadequate Hot Liquid Safety and Supervision
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but had upper extremity impairment and required total staff assistance with eating, was provided with hot water for soup by a CNA. The CNA obtained the hot water from a dispenser in the coffee room, which was later measured to be 167.6 degrees Fahrenheit. The CNA informed the resident that the water was hot and left the room. While the CNA was away, the resident accidentally spilled the hot water on her leg, resulting in second and third degree burns. The incident was reported to the LVN, who assessed the resident and initiated treatment, but the resident was not sent to the emergency room despite her request and the severity of the burns. The resident's care plan did not include interventions or precautions related to being served hot liquids, despite her need for total assistance with eating and her physical impairment. Staff interviews revealed inconsistent practices regarding the testing of hot liquid temperatures before serving to residents, and there was no clear process or designated responsibility for ensuring the safety of hot liquids dispensed from the coffee machine. Some staff relied on subjective methods, such as touching the outside of the cup, and there was no thermometer available for checking temperatures. Additionally, the facility's incident log did not reflect the burn incident, and staff were not uniformly aware of protocols for hot liquid safety. Observations confirmed that the hot water dispenser was accessible to all residents, and there was a lack of oversight or monitoring of the area. Interviews with facility leadership, including the DON and Nutritional Director, indicated uncertainty about who was responsible for monitoring hot liquid temperatures and ensuring resident safety in the coffee room. The facility's policy required immediate reporting and documentation of accidents, but this was not followed in the case of the burn incident. These actions and inactions led to a situation where a resident suffered significant burns due to inadequate supervision and lack of safety measures regarding hot liquids.