Failure to Implement Safety Measures After Hot Liquid Spill Causing Skin Impairment
Penalty
Summary
The facility failed to implement safety measures for a resident who sustained impaired skin integrity after spilling hot liquid on the right forearm. The resident was re-admitted with diagnoses including type 2 diabetes, hypertension, kidney disease, and peripheral vascular disease, and required assistance with ADLs per the quarterly MDS. Review of the resident’s ADL care plan and impaired skin integrity care plan showed no safety interventions related to the right forearm skin impairment caused by the hot liquid spill. The facility’s skin policy stated that preventive measures would be implemented according to the resident’s assessed risk level and risk factors for skin integrity impairment. Progress notes documented that the resident’s family reported a fluid-filled discoloration on the right forearm, and the resident stated she had spilled coffee on her arm but reported no pain. Physician orders were in place for treatment of the right forearm skin impairment, including cleansing with normal saline, applying antibiotic ointment, and leaving the area open to air twice daily and PRN, but there were no orders for adaptive equipment or other safety measures related to the injury. During interview, the Regional Nurse Consultant confirmed that no safety measures or interventions had been implemented for the impaired skin integrity from the hot liquid spill and stated that sippy cups had been ordered for the resident but were not implemented.
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