F0609

J

Failure to Report Alleged Neglect and Implement Safeguards After Coffee Burn and Impaired Nurse Incidents

Picayune, Mississippi Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report allegations of neglect to the State Agency (SA) for two separate events and to implement timely safeguards after serious incidents. In the first event, a resident sustained a burn injury on the left thigh when hot coffee was spilled on the resident’s hip area on 12/31/25 at approximately 3:40 PM. The incident report documented that another resident had given the resident a cup of coffee, which then spilled and caused blistering to the front left thigh/hip area, with wound measurements recorded as approximately 7.06 cm by 7.56 cm and identified as an in-house acquired skin issue. Despite this injury, there was no documentation indicating that interventions were initiated to prevent recurrence or to safeguard other residents who had access to hot coffee.

The DON later confirmed that the resident’s burn occurred when another resident provided hot coffee that spilled onto the resident’s leg, and that nursing staff cleansed the area, measured the wound, applied a dressing, and notified the medical provider. However, the DON stated she was not aware of the coffee burn until she returned to the facility on 1/2/26, and confirmed that no immediate interventions were put in place at that time to protect other residents who drink coffee. The coffee machines were not removed; instead, signs were added on 1/6/26 instructing not to use the machines, while the facility began using coffee carafes. On 1/12/26, surveyors observed that a coffee machine in the dining area remained plugged in, operational, and accessible to residents, with hot coffee obtainable without staff assistance or supervision, and no physical barriers in place despite the posted signage.

In the second event, the facility failed to immediately report and adequately address an incident involving an impaired LPN responsible for resident care and medication administration on the night shift beginning 12/29/25. The DON received a call at approximately 1:30 AM on 12/30/25 from another LPN reporting that the nurse on Station 2 was unable to complete the medication pass, kept falling asleep, and appeared impaired. Camera footage reviewed by the DON showed the impaired LPN at the nurse’s station and medication cart for about two hours, swaying, stumbling, appearing under the influence, repeatedly falling asleep at the med cart, and being awakened multiple times by CNAs. Statements from CNAs described the LPN falling asleep standing up, crying loudly, going to the bathroom frequently, being “half out of it,” unable to stay awake to pull or pass medications, and failing to administer medications so that residents repeatedly called for their meds. Medication administration audit reports later showed that 25 residents had medications with no administration time documented and 5 residents had medications documented as administered late.

The impaired LPN remained on duty and responsible for resident care until approximately 3:00–3:30 AM, when a replacement nurse arrived, and was later discharged from employment. Another LPN who relieved the impaired nurse reported that she was very drowsy, unable to give report, stumbling, and unable to participate in the narcotic count. The Administrator acknowledged awareness of the incident involving the impaired LPN on the 12/29 PM shift and confirmed that the nurse remained on duty for about eight hours until a replacement arrived. The Administrator also acknowledged awareness of the resident’s coffee burn but stated he did not learn of it until six days after it occurred. He reported that he did not consider either the impaired nurse incident or the coffee burn incident to be neglect and therefore did not report them to the SA as alleged violations, despite the facility’s policy requiring prompt reporting of alleged neglect to local, state, and federal agencies.

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 and started that indicate the staff member who tested the temperature of the coffee, the time and date.
• Coffee temperature logs will be turned into the Administrator daily.
• Training for all staff 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 content includes accidents and supervision including implementing immediate interventions.
• Training content includes abuse and neglect reporting and investigation.
• Training content includes the hot liquids policy.
• Training content includes notification of the Administrator and Director of Nursing (DON) of unusual occurrences, high risk events, and timely notification.
• Training content includes charge nurse delegation and duties to include the assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse.
• If the assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment.
• The DON and Administrator's phone numbers are posted on the Facility Assignment Grid.
• In the event that the charge nurse is impaired, the DON and Administrator will be contacted.
• The Facility Assignment Grid was updated to include assignment for designated charge nurse.
• Training content includes medication administration documentation.
• All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
• The 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 adequately identified 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.
• Emergency Quality Assessment and Assurance Committee Meeting held.
• The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made.
• Summary of incident was discussed with actions taken including 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 that she works for and is not allowed to work at this facility.