F0689

G

Failure to Supervise Resident With Hot Liquids Resulting in Repeated Burns

Portage, Michigan Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and protection from accident hazards related to hot liquids for a resident with significant functional limitations, resulting in two burn injuries. The resident had a history of nontraumatic intracerebral hemorrhage with flaccid hemiplegia affecting the left dominant side, chronic pain, and depression. On admission, the nursing evaluation documented that the resident was at risk of hot liquid spills due to weakness/paresis and reduced mobility in the upper extremities, and the care plan and Kardex both indicated the resident required one-person assistance with eating. The MDS also reflected that the resident needed partial/moderate assistance with eating. Despite this, there was no documentation in the care plan or Kardex that the resident was at risk for hot liquid spills or required special equipment to reduce that risk.

On the first incident date, staff provided the resident with hot coffee in her room. A CNA reported that the resident had previously spilled soda on herself and the bed and asked an RN if the resident could have coffee; the RN allowed it. The CNA placed a lidded cup of coffee on the bedside table and left the resident alone. Later, staff found that the resident had spilled the coffee and sustained a burn on her left lower forearm. The resident’s family member stated that the resident had a stroke, had left-sided paralysis, used only her right (non-dominant) hand, and needed assistance with meals and drinks, and that she had informed staff of this. The resident herself reported that the coffee lid was on the cup but fell off when she took a drink, and that she needed help with meals and drinks. Clinical documentation and photographs showed an in-house–acquired burn on the left inner forearm with open skin, redness, pain, and later blistering consistent with a second-degree burn. The nurse who first treated the burn did not apply cool water and instead used triple antibiotic ointment and a non-adherent dressing, contrary to external burn first-aid guidance cited in the report and to the expectations later described by facility clinical leadership.

A second burn incident occurred a few days later, again involving hot coffee. On that day, a CNA brought the resident a cup of coffee at her request, not knowing about the prior burn. The Kardex indicated the resident was a one-person assist for meals, but there were still no specific interventions regarding hot liquids or assistive devices documented or communicated to staff. The resident was again left alone with hot coffee and subsequently spilled her lunch plate and coffee on herself and the floor. When another CNA responded to the call light, the resident’s left hand was noted to be red, and cool water was poured over the area. The unit manager observed spilled coffee on the bed and floor and redness of the left hand. Staff interviews confirmed that the resident was known to need assistance with meals due to left-sided weakness and a shaky right hand, and that she was considered a one-to-one assist at meals. However, the hot liquid safety assessment process described in facility policy was not effectively implemented: although the admission assessment identified the resident as at risk for hot liquid spills, this risk was not translated into specific, documented interventions on the care plan or Kardex, and there was no systematic communication to direct care staff about hot liquid precautions prior to the second burn.

The facility’s own Hot Liquids/Food Assessment Policy required that when a resident is identified as having concerns with handling hot liquids, a hot liquids safety evaluation should be completed and immediate interventions such as cooling liquids, use of lids, avoidance of hot liquids until evaluation, therapy evaluation, IDT review, and an immediate plan of care should be implemented and added to the care plan and Kardex. The Use of Assistive Devices Policy required IDT collaboration to provide and support assistive devices and staff training. Despite these policies, the unit manager stated that the facility did not do anything different for residents at risk for hot liquid spills because all residents received plastic lids, and that such risk would not be specifically communicated. The administrator acknowledged that no interventions were put in place after the first burn and that no full staff education occurred. Dietary staff monitored coffee temperatures but not all hot liquids, and there was no separate documentation line for hot water temperatures. Therapy only formally evaluated the resident for assistive devices and dining-room supervision after the second burn. Collectively, these actions and inactions led to the resident twice being left unsupervised with hot coffee despite known physical limitations and documented assistance needs, resulting in two burn injuries and the resident’s expressed fear of being burned again.