F0600

J

Failure to Protect Residents From Hot-Liquid Burn Hazard and Care by Impaired Nurse

Picayune, Mississippi Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from neglect in two primary areas: exposure to a known hot-liquid burn hazard and allowing an impaired nurse to remain responsible for resident care and medication administration. On one occasion, a resident with dementia and a severely impaired BIMS score of 03 sustained a burn to the left hip/thigh area when another resident gave him hot coffee, which was then spilled, causing blisters and a new in-house skin issue measuring 7.06 cm by 7.56 cm. The incident report documented that the resident cried out in pain, and subsequent emergency department documentation confirmed the burn was from a coffee spill at the facility. Despite this event, residents continued to have access to hot coffee in the dining room without supervision, temperature controls, or access restrictions for nearly two weeks.

The facility also failed to intervene appropriately when an LPN on the night shift was impaired and unable to safely perform nursing duties. Staff statements and camera footage showed the nurse repeatedly falling asleep standing up, leaning over the med cart with eyes closed, crying loudly, moaning, swaying, stumbling, and nearly falling. CNAs reported that residents were calling for their medications, that the nurse fell asleep at the med cart and on the counter in the nurse’s station, and that she repeatedly went to the bathroom for long periods. The DON was notified by another nurse at 1:30 AM that the impaired nurse could not complete the med pass and kept falling asleep, but the impaired nurse remained in the building and responsible for resident care until approximately 3:00–3:30 AM. There was no designated charge nurse on that shift after the scheduled charge nurse called in sick, and no nurse was assigned to supervise staff, coordinate care, or respond to the unsafe condition.

Medication administration records and audit reports showed that multiple medications were either not documented as given or were documented late for residents on the impaired nurse’s unit. For four sampled residents, there was no documentation that scheduled evening and bedtime medications were administered on the night in question, including Donepezil for dementia, Crestor, Latanoprost, Novolog, Trazodone, Gabapentin, Duloxetine, Keppra, Lacosamide, and ordered accuchecks. One cognitively intact resident reported being in the dining room, observing that the nurse appeared impaired and unable to safely administer medications, and stated he did not receive his medications and would have been afraid to take them from her. Another cognitively intact resident reported that his medications and blood sugar check were not done and that a CNA told him something was wrong with the nurse. The facility’s own medication administration audit identified 25 residents with missed medications and 5 residents with late medications on that unit during the relevant time frame, and staff confirmed that another LPN pulled medications for the impaired nurse without observing administration, verifying correct resident, or documenting on the MAR, while the impaired nurse retained responsibility and control of narcotic keys.

The Administrator acknowledged awareness that the impaired nurse remained on duty until a replacement arrived and that he was not informed of the coffee burn incident until several days after it occurred. He confirmed that, although leadership discussed modifying the coffee service process after he learned of the burn, he did not verify that any changes were implemented or monitored. When surveyors arrived, they were able to obtain hot coffee directly from a dining room machine that was still operational despite signage indicating it was out of service, and the Administrator acknowledged that residents had continued access to hot coffee and that no system had been in place to ensure the discussed intervention was followed. The State Agency determined that these failures to safeguard residents from a known burn hazard and to remove an impaired nurse from resident care created Immediate Jeopardy and substandard quality of care under F600, beginning when residents remained under the care of the impaired nurse.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created to indicate the staff member who tested the temperature of the coffee and the time.
• Coffee temperature logs will be turned into the Administrator daily.
• Training for all staff will be completed prior to their next scheduled shift.
• No staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse.
• Training will include: accidents and supervision including implementing immediate interventions; abuse and neglect reporting and investigation; hot liquids policy; notification of Administrator and DON of unusual occurrences/high risk events and timely notification; charge nurse delegation and duties including assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse and process if assigned charge nurse calls off; posting DON and Administrator phone numbers on the Facility Assignment Grid; requirement to contact DON and Administrator if charge nurse is impaired; updated Facility Assignment Grid to include designated charge nurse; medication administration documentation.
• All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
• Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
• The Facility Assessment was updated by the Administrator to include a contingency plan for absence of supervisory nursing staff and to identify staffing needs by shift and building.
• The facility's Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
• The Scheduler and the Staff Development Nurse were inserviced by the DON on the new Assignment Grid and charge nurse delegation.
• The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
• An emergency Quality Assessment and Assurance Committee meeting was held to review the Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy and to discuss the incident summary, actions taken, training, and monitoring.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving LPN #1.
• LPN #2 was reported to the agency she works for and is not allowed to work at this facility.