Inadequate Supervision and Hot Beverage Handling Resulting in Resident Burn
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment, resulting in a hot liquid burn to one resident. Facility policy on Accidents and Incidents stated that a safe environment would be provided for all residents. The resident involved had diagnoses including high blood pressure, muscle weakness, and a need for assistance with personal care, as documented on an MDS assessment. On the date of the incident, a change in status note recorded that the resident was served a dinner tray, took her tea to drink, and dropped it on herself, resulting in burns to multiple areas including the right thigh, left inner and outer thigh, and right and left lower and upper abdominal quadrants, with specific burn measurements documented. An Emergency Department note stated that a staff member at the nursing home accidentally dropped hot water for tea on the resident, causing a superficial first-degree burn to the upper abdomen and right thigh, with no blistering. Witness statements from dietary staff indicated that hot beverages were poured for residents without checking the temperature of the coffee/tea water, and that the dietary aide was on the other side of the dining room with her back to the resident when the resident cried out. Another statement from the resident’s tablemate reported that a kitchen staff member poured hot water into the resident’s cup, moved on to other tables, and was on the other side of the dining room when the resident screamed and the cup was seen tipped over. The Nursing Home Administrator confirmed that kitchen staff did not check the temperature of the water before service and that, at the time of the incident, two dietary staff were in the dining room while the assigned nurse aide was occupied bringing another resident to the dining room, resulting in inadequate supervision and a burn injury to the resident.
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