Failure to Supervise and Assess Hot Liquid Risk Leads to Resident Burn
Penalty
Summary
The facility failed to follow its own hot liquids policy, did not identify potential hazards related to hot liquids, and did not provide adequate staff supervision to prevent an accident involving hot liquids. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including dementia, hallucinations, and repeated falls, was not assessed for hot liquid risk as required by facility policy. The resident was left unsupervised in the dining room during meal service, despite being at risk for injury from hot liquids. No hot liquid burn interventions were in place for this resident prior to the incident. As a result, the resident spilled hot chocolate on her left thigh during lunch, sustaining second-degree burns with three blisters. The incident was unwitnessed by staff, and the resident reported that no staff were present in the dining room at the time. Documentation confirmed that the required Hot Beverage Use Assessment had not been completed for the resident, and the Director of Nursing acknowledged that the facility had not been following its hot liquids policy prior to the incident.