Failure to Follow Care Plan for Hot Liquid Burn Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned interventions to reduce a resident’s risk for burns from hot liquids. The resident had diagnoses including parkinsonism, depression, anxiety, and dementia, but was care planned as having intact cognition and able to eat independently. Her care plan, dated 12/11/25, identified a risk for altered nutritional status and directed staff to provide covered mugs for hot liquids when she was outside the dining room. A Hot Liquid Safety Evaluation dated 9/19/25 documented that hot liquid temperatures were not to exceed 180 degrees and noted an isolated coffee spill event on 9/16/25, with follow-up completed on 9/17/25. Progress notes from 9/17/25 recorded that the resident reported spilling coffee in her lap while watching television and stated the coffee was “luke warm at best,” and the event was considered isolated. On 12/10/25, progress notes documented pink/red areas on the resident’s left inner thigh (10 cm x 6 cm) and right inner thigh (13 cm x 3 cm), warm to touch and tender, with the cause identified as the resident spilling coffee in her lap. Staff were then directed to put covers on hot liquids when she took them outside the dining room, and an interdisciplinary team review on 12/11/25 confirmed that she had spilled coffee while attending a movie activity and that the care plan was updated to require covered mugs for hot beverages outside the dining room. However, during an observation on 1/14/26, the resident was seen in her room with a hot coffee cup without a lid and stated she was supposed to have a lid but staff had not given her one. A NA-C and RN both indicated the resident was supposed to have covered cups when not in the dining room, and the interim DON stated the resident should have a cover on her cup as directed in the care plan. Facility policy stated that the care plan is to be used to develop residents’ daily care routines and that health care personnel are responsible for following the care plan, but this was not followed for this resident’s hot liquid precautions.
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