Failure to Provide Required Adaptive Drinking Device Upon Readmission
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, diabetes, peripheral vascular disease, congestive heart failure, and chronic obstructive pulmonary disease was readmitted to the facility following a hospital transfer. The resident had a documented need for a Kennedy cup, an adaptive drinking device, for all hot and cold liquids due to a risk of aspiration and a history of spilling drinks. Upon readmission, the nursing assessment did not identify any changes in functional status, but the order for the Kennedy cup was not reactivated, as it had been discontinued during the hospital transfer and was not included in the hospital's transfer documentation. On the day of readmission, the resident was served hot coffee in a regular cup with a lid, rather than the required Kennedy cup. The resident removed the lid and spilled the coffee on their right thigh, resulting in a second-degree burn measuring 17 cm by 9.5 cm. The temperature of the coffee was measured at 171 degrees Fahrenheit. Nursing staff responded to the incident, and subsequent assessments documented the extent of the burn and the resident's pain level. The Kennedy cup was not provided until after the incident occurred. Interviews with staff revealed that the nurse aide assigned to the drink cart was unaware of the resident's need for a Kennedy cup, as the resident was not listed as requiring special equipment on the drink cart list. The occupational therapist confirmed the resident's long-standing need for the Kennedy cup and noted that the order had not been reactivated upon readmission. The Director of Nursing acknowledged that there was no process in place to reconcile previous orders or interventions upon readmission, which led to the omission of the Kennedy cup and contributed to the resident's injury.