Failure to Prevent Burn Injury and Update Care Plan After Resident Spill of Hot Soup
Penalty
Summary
Facility staff failed to ensure that all residents were kept as free from accident hazards as possible when they did not implement steps to prevent future burns and did not update the care plan regarding a burn incident for a resident who suffered burns after spilling hot soup on themselves. The resident, who was cognitively intact and used both a motorized and manual wheelchair independently, had significant medical history including bilateral above-the-knee amputations, long-term kidney disease, major depressive disorder, anxiety, PTSD, and peripheral vascular disease. The resident was independent at meals and typically heated their own food using a microwave located in a room on the unit hall. On the day of the incident, the resident was carrying a bowl of hot tomato soup in their wheelchair when they ran into a door, causing the soup to spill onto their abdomen and chest. Initial nursing notes indicated that cool cloths were applied and the area was left open to air per physician instructions. However, within two days, the affected areas developed fluid-filled blisters, some of which had popped, requiring wound care treatment. The care plan was not updated to reflect the new risk or to include interventions to prevent future burns, and no hot food/hot liquid risk assessment was completed for the resident. Interviews with staff revealed that there was no policy regarding resident use of microwaves, and the rooms containing microwaves were not locked, allowing any resident access despite signs indicating they were for employees only. Staff reported that residents were not supposed to use the microwaves without assistance, but enforcement was inconsistent, and the resident in question frequently used the microwave independently. There was no documentation of risk assessments or care planning related to hot food or microwave use for any residents, and staff were generally unaware of any such policies or procedures.