Failure to Prevent Accident Hazard and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a need for supervision during ambulation was allowed to ambulate independently while carrying a cup of hot coffee. The resident, who had diagnoses including heart failure, seizure disorder, and mood disorder, spilled hot coffee on their right hand while walking in the hallway using a rolling walker. The incident resulted in a third-degree burn with blisters, requiring medical assessment and wound care. Facility policies required that residents not use microwaves and that staff provide supervision and assistance to prevent accidents. However, the resident was able to access the microwave to reheat coffee without staff assistance, and there were no documented care plan instructions or CNA documentation indicating the need for ambulation supervision. Staff interviews revealed that CNAs and nurses were unaware of the resident's supervision needs during ambulation, and the resident did not request help because they believed staff were busy. The lack of clear communication and documentation contributed to the resident's unsupervised activity and subsequent injury. After the incident, there was a delay in notifying the nursing supervisor and physician, as well as incomplete and unclear documentation in the huddle book. Multiple staff members, including nurses and the DON, confirmed that the incident was not reported promptly and that there was confusion regarding the resident's care needs. The facility's investigation concluded that there was no abuse or neglect, but the failure to provide a hazard-free environment and adequate supervision directly led to the resident's injury.