Failure to Report and Care Plan for Resident at Risk for Hot Liquid Burns
Penalty
Summary
The deficiency involves the facility’s failure to report an incident of neglect related to hot liquid burns and to implement appropriate interventions after an initial burn, resulting in a second burn to the same resident. The resident had a history of nontraumatic intracerebral hemorrhage with flaccid hemiplegia affecting the left dominant side and was assessed on admission as being at risk for hot liquid spills due to upper extremity weakness and reduced mobility. The resident’s MDS showed intact cognition, and the care plan and Kardex identified a one-person assist for eating but did not include any interventions or information regarding risk for hot liquid spills or special equipment to reduce that risk. On one occasion, the resident’s family member found the resident covered in dried coffee with a burn on the left forearm that was red, swollen, with peeled skin, and the resident complained of pain. An incident report documented that staff notified an LPN that the resident had spilled coffee and burned herself, and the daughter stated the resident was not supposed to be left alone with hot drinks. CNAs reported that the resident was a one-to-one assist with meals because her right (non-dominant) hand was shaky and that the Kardex should indicate if assistance with hot beverages was needed. The resident herself reported having two burns on her left arm/hand, described the first burn as severe with blisters, and stated that although the coffee lid was on the cup both times, it fell off when she took a drink; she also stated she was left-handed, had to use her right hand due to left-sided neglect, and needed help with meals and drinks. A second incident report documented another hot coffee spill in which a CNA responded to the resident’s call light and found coffee spilled on the bed and floor, with the resident’s left hand noted to be red and blanching. The Unit Manager confirmed that a hot liquid safety assessment completed on admission identified the resident as at risk for hot liquid spills, but stated that the facility did not do anything specific with these assessments for high-risk residents beyond providing lids on cups, and that this risk was not otherwise communicated. The Nursing Home Administrator stated the first burn was not reported because it was not considered an injury of unknown origin, despite the facility’s abuse/neglect policy defining neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and listing failure to provide care needs such as comfort and safety as a possible indicator of abuse or neglect.
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