Failure to Prevent Burn Injury from Hot Liquid Due to Lack of Supervision and Hazard Controls
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and limited upper extremity mobility was provided with hot water in a cup without a lid by a medication aide. The resident, who required substantial to maximal assistance with eating and had a care plan indicating a need for lids on cups containing hot liquids, spilled the hot liquid in her lap, resulting in a burn to her thigh. The medication aide was unaware of the resident's need for a lid, and the hot water was heated in a microwave without temperature verification or the use of a lid, contrary to the resident's care plan interventions. The incident was documented in nursing notes, which described the resident notifying staff after the spill, with subsequent assessment revealing a scald mark and later a blister on the thigh. The resident reported that the cup slipped from her fingers, and she did not have a lid on her mug at the time of the incident. The care plan for this resident specifically identified a risk for burns from hot liquids and required the use of a cup with a lid and temperature controls for hot beverages, but these interventions were not followed during the event. Staff interviews confirmed that, at the time, there was a lack of awareness among some staff regarding which residents required lids for hot liquids. The medication aide involved stated she was not informed of the resident's need for a lid. The facility had microwaves accessible throughout the building, and there was no system in place to ensure only authorized staff prepared hot liquids or that temperature and safety interventions were consistently implemented for at-risk residents.