Failure to Prevent Burn Injury from Hot Beverage Due to Inadequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate assistance devices to prevent accidents for two of five residents reviewed for accidents and hazards. Specifically, a cognitively intact female resident who used a wheelchair and required only setup assistance with eating was given a cup of hot tea by a CNA. The CNA prepared the tea using a hot water dispenser, did not check the temperature, and handed the cup directly to the resident while she was in her wheelchair. The resident, while independently moving to a vending machine and holding the cup, accidentally spilled the hot tea onto her lap, resulting in a second-degree burn on her left upper thigh. The incident was discovered when staff assisted the resident with a clothing and brief change and noticed a red, blistered area on her thigh. The resident reported that she had spilled hot tea on herself earlier. The injury was assessed as a 3 cm x 6 cm area with approximately 25% blistering. The resident did not initially report pain and continued her activities until the injury was discovered. The CNA involved acknowledged that she should have placed the tea on a table for the resident rather than handing it to her directly and admitted to not checking the temperature of the beverage before serving it. Interviews and record reviews revealed that prior to the incident, staff, including CNAs and dietary personnel, did not consistently check the temperature of hot beverages before serving them to residents, nor did they ensure the use of lidded cups for residents who were mobile or at risk for spills. The facility's policy required precautions to limit the risk of burns from hot beverages, including temperature checks and the use of lids for at-risk residents, but these procedures were not followed at the time of the incident. The failure to adhere to these safety protocols resulted in the resident sustaining a burn injury from the hot tea.