Failure to Assess and Supervise Residents with Hot Beverages Results in Burn Injury
Penalty
Summary
The facility failed to adequately monitor and assess three residents for safety with hot liquid beverages, resulting in incomplete safety assessments for two residents and physical harm to another. One resident with severe cognitive impairment and a history of Alzheimer's disease and vascular dementia was served hot coffee from a Keurig machine in the activity room without a lid or ice, contrary to dietary instructions. The staff member prepared the coffee, placed it on the table, and then turned away, during which time the resident spilled the coffee onto himself, sustaining second-degree burns to his abdomen, left arm, and left thigh. The temperature of the coffee was later found to be between 177.6 and 178.7 degrees Fahrenheit, exceeding the facility's policy range of 140 to 160 degrees Fahrenheit for serving hot beverages. Further review revealed that another resident with mild cognitive impairment had not received a hot liquid safety assessment since a previous date, despite using the Keurig machine during activities. A third resident, who was cognitively intact, had no completed hot liquid assessment since admission or readmission. The facility's policy required all residents to be assessed for their ability to handle hot beverages on admission, quarterly, annually, and upon significant change in status, and mandated the use of hard plastic lids on cups. These requirements were not consistently followed, leading to the cited deficiencies.