Burn Injury from Unsupervised Hot Liquid Near Resident with Parkinson’s Disease
Penalty
Summary
The deficiency involves the facility’s failure to prevent an avoidable burn injury to a resident with Parkinson’s disease by not adequately considering his functional limitations and by leaving hot liquid within his reach and unattended. The resident was admitted with Parkinson’s disease and had moderately impaired cognition. His MDS assessment indicated he required substantial/maximal assistance with ADLs and supervision or touch assistance with eating. Staff were therefore aware that he had tremors, poor coordination, impaired mobility, and could not independently bring a utensil or cup to his mouth. On the day of the incident, CNA 1 placed the resident’s lunch tray, which included a cup of hot water, on the overbed table and positioned the table halfway over the resident’s legs near his knees. CNA 1 then left the resident unattended and went to assist the roommate with his lunch tray. While CNA 1 was assisting the roommate, she saw the cup of hot water falling from the resident’s tray and attempted, unsuccessfully, to catch it before it spilled onto the resident. CNA 1 later acknowledged that the resident experienced frequent shaking in his upper extremities, required a lot of assistance when eating, and that she should not have placed the tray with hot water so close to him because he could have grabbed the cup and caused it to fall. Following the spill, LVN 1 observed a wet, warm blanket over the resident’s legs, a cup on top of the blanket, and a fresh red wound with peeling skin on the resident’s right leg. Nursing documentation and a change of condition note described a thermal burn with erythema and superficial skin peeling consistent with a partial-thickness burn to the right lateral leg, and a podiatrist later classified the injury as a second-degree burn involving the epidermis and dermal layers. The DON stated that the resident’s fine motor skills were limited and that his lunch tray with hot items should not have been left unattended. The facility’s accidents and supervision policy required staff to observe and identify potential hazards in the environment while considering each resident’s unique characteristics and abilities, which was not followed in this case.
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