F0610

J

Failure to Investigate Neglect and Control Hazards After Coffee Burn and Impaired Nurse Incident

Picayune, Mississippi Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The facility failed to conduct thorough and timely investigations and to implement safeguards following two separate events involving potential neglect. In the first event, a resident sustained a burn on the left thigh on 12/31/25 at approximately 3:40 PM after another resident gave the resident a cup of hot coffee, which was then spilled, resulting in blistering. Nursing documentation described a new in-house acquired skin issue on the front left trochanter, with a blister measuring 7.06 cm by 7.56 cm. Although staff cleansed the area, measured the wound, applied a dressing, and notified the medical provider, there was no documentation of interventions to prevent recurrence or to safeguard other residents who drink coffee immediately after the incident.

The facility did not promptly identify or control the environmental hazard associated with resident access to hot coffee. On 1/12/26 at 7:20 AM, surveyors observed a coffee machine in the dining area that was accessible to residents, labeled out of service but still plugged in and operational. The State Agency was able to obtain hot coffee from the machine without staff assistance or intervention while residents were present in the dining area, and no staff were observed supervising or restricting resident access. No physical barriers were in place to prevent resident use of the machine despite the posted signage. The DON confirmed that no immediate interventions were implemented to safeguard other residents who drink coffee between the time of the burn on 12/31/25 and 1/6/26, and did not describe interviewing residents who drink coffee, reviewing procedures to check coffee temperatures, or assessing environmental risks related to access to hot liquids.

In the second event, the facility failed to thoroughly investigate and respond to an impaired nurse who was responsible for resident care and medication administration. On the 12/29/25 7:00 PM–7:00 AM shift, an LPN on Station B appeared impaired, repeatedly fell asleep standing up and at the med cart, cried loudly, and was described by CNAs as half out of it, with legs giving out and requiring a chair placed behind her. Camera footage reviewed by the DON showed the nurse swaying, almost falling, stumbling, staring at the med cart and medication cards for extended periods, and falling asleep at the med cart in the dining room while a resident was present. CNA statements indicated that residents repeatedly called for their medications, that the nurse did not complete the med pass, and that no one received medications for a period, while the nurse remained on duty until approximately 3:00–3:30 AM. Medication Administration Audit Reports for Station B showed 25 residents with medications documented as missed and 5 residents with medications documented as administered late during this time frame.

The DON was notified at approximately 1:30 AM by another LPN that the nurse on Station B was unable to complete the med pass and kept falling asleep, but the DON only verbally confirmed with the reporting nurse that residents had received their medications and did not verify this by reviewing Medication Administration Records, Medication Audit Reports, or interviewing residents. The DON did not describe reviewing all events leading up to and following the incident to determine root cause or to prevent recurrence. The Administrator acknowledged awareness of the impaired nurse incident and that the nurse remained on duty until a replacement arrived about eight hours after the start of the shift, but he did not review MARs, Medication Audit Reports, or other documentation to verify whether medications were administered accurately and timely. The facility’s own investigation documents and counseling/discipline report for the impaired LPN noted that the nurse did not complete the med pass and only gave medications to two residents, yet there was no evidence of a comprehensive investigation consistent with the facility’s Abuse Investigation and Reporting policy, which requires thorough review of documentation, medical records, interviews with residents and staff, and review of all events leading up to the alleged incident.

The Administrator and DON both confirmed that they did not initiate formal investigations consistent with facility policy for either the coffee burn or the impaired nurse incident. For the coffee burn, the Administrator stated he was not aware of the incident until six days after it occurred and confirmed there were no immediate interventions to safeguard other residents who drink coffee or to assess environmental risks related to access to hot liquids immediately following the incident. For the impaired nurse, the Administrator acknowledged he relied on being told that residents had received their medications and did not independently verify medication administration accuracy or timeliness. These actions and inactions resulted in the facility failing to investigate alleged neglect, failing to prevent further potential neglect, and allowing unsafe conditions to continue for residents with access to hot coffee and for all residents on Station B 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 document the staff member who tested the coffee temperature and the time/date.
• Coffee temperature logs will be turned into the Administrator daily.
• All staff will be trained 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.
• Staff training topics 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 notification process if assigned charge nurse calls off); Medication Administration Documentation.
• DON and Administrator 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.
• Facility Assignment Grid was updated to include assignment for designated charge nurse.
• 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.
• 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.
• Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
• Scheduler and Staff Development Nurse were inserviced by the DON on the new Assignment Grid and Charge Nurse Delegation.
• 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 was held with interdisciplinary attendance and the Medical Director present via telephone.
• The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made.
• The incident summary was discussed with actions taken including training and monitoring.
• Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator regarding the incident involving LPN #1.
• LPN #2 was reported to the agency she works for and is not allowed to work at this facility.