complaint·April 20, 2021

This is an amended report. LPA also reviewed facility documents and video evidence on 6/11/2020 and 4/19/2021, and medical records on 3/12/2021. Resident 1 (R1)’s Physician Report, dated 04/03/2019, indicated that R1 had dementia and anxiety, could be confused and disoriented, and was able to feed self. The facility’s Appraisal Needs and Services (ANS) Plan, dated 05/20/2019, also stated R1 had dementia and anxiety, and did not indicate R1 needed assistance with feeding. Interviews with Administrator, Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), and Family Member 1 (F1) indicated that R1 had a specific routine of mixing hot tea and juice multiple times daily. On 05/09/2020, at approximately 10:55am, R1 requested their hot water for tea from the kitchen, per R1’s routine. S1 poured the water from the Chefman electric kettle into the cup, placed the lid on the cup and provided the cup to R1. R1 then took the cup to their recliner chair. According to interviews, R1’s juice was typically kept on R1’s walker. All staff interviewed could not verify that R1’s juice was on their walker during this incident. LPA reviewed video footage of the incident from the facility’s cameras. The video shows R1 holding the cup, without a lid, and blowing on the top of the cup. Then R1 tries to take a sip and the liquid in the cup spills on R1’s chest and lap. R1’s cup lid and juice are not visible in the video and R1’s walker does not appear to have been within R1’s reach. R1 was taken to the Emergency Room (ER) by Family Member 2 (F2) on 5/9/2020. ER medical records indicate R1 sustained first and second-degree burns on the chest and leg. The manufacturer specification of the Chefman Electric Kettle indicate that water comes to a boil (212 degrees Fahrenheit), then the kettle automatically turns off. None of the staff interviewed indicated that they tested the temperature of the water being served to R1. R1 had been doing this routine independently several times a day for years, and the facility staff would not have known R1 was likely to spill the hot tea. The facility revised their food service procedure policy for serving hot beverages to avoid future similar issues. Based on the information obtained, the allegation is deemed unsubstantiated at this time. Exit interview conducted, copy of report and appeal rights emailed.