146172
03/20/2025
Spring Creek
777 Draper Avenue Joliet, IL 60432
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
Based on observations, interviews and record reviews the facility failed to implement safety interventions and provide supervision to prevent a resident from injury when drinking hot liquids. This failure resulted in R1 sustaining 1st and 2nd degree burns to her chest. This applies to 1 of 3 residents (R1) reviewed for dependent assistance with feeding in a sample of 4. The findings include: R1's electronic health record showed that on 3/9/25, R1 was sent to the local community hospital for evaluation and treatment to burns on her chest. R1 has diagnoses including quadriplegia (loss of motor and sensory function in all four limbs), C5 - C7 complete. On 3/18/25 at 10:50 AM R1, who is alert and oriented, was in her bed with a picture of water and a large cup of ice coffee with extra-long flexible straws that reached R1's mouth. R1 said that on 3/9/25 she was alone drinking her hot cup of coffee. The cup of coffee did not have a lid on the cup, and she used a straw to drink it. R1 said coffee came out of the straw and burned her chest and she was sent to the emergency room for the burns. R1's 3/13/25 11:12 AM Nursing Progress Note showed that on 3/9/25 R1 was sent to the emergency room for burns to her chest due to coffee spillage. The progress note showed that R1 said that the coffee came out of the straw and on to her chest. R1's emergency report of 3/9/25 showed that the left side of R1's chest wall, and along the left side of the clavicle had 1st and 2nd degree burns with 2 areas of blistering. R1's 9/25/24 Fluoroscopic Swallowing Study recommendations showed, supervision 1:1, and liquid viscosity thin, no straws. R1's 3/9/26 MDS (Minimum Data Set) section GG showed that R1 is dependent on staff for eating. R1's 2/17/25 care plan showed R1 is at risk for aspiration with interventions of no straws and assess for residual food in mouth. R1's 3/10/25 Wound Notes showed that R1 had 15.2 cm x 16.8 cm burns to upper chest with a surface area of 255.36 cm, along with fluid filled blisters. The report showed an order for Silver
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146172
146172
03/20/2025
Spring Creek
777 Draper Avenue Joliet, IL 60432
F 0689
Sulfadiazine to be applied twice a day for 30 days.
Level of Harm - Actual harm
On 3/18/25 at 2:08 PM, V4 CNA (Certified Nurse's assistant) said that on 3/9/25 around 10 - 1030 am R1 asked her to warm up her cup of coffee. V4 said she warmed the coffee up in the microwave for 30 seconds and gave it back to R1. V4 said that R1 said it was still not hot enough and V4 said she warmed it up again for another 30 seconds. V4 said that R1 tested it again, and this time R1 said it was okay. V4 said the cup of coffee was without a lid and had a straw in it. V4 said she left R1 with the cup of coffee to drink it unsupervised. V4 said about 10 minutes later she was told that R1 had burned herself from the coffee.
Residents Affected - Few
On 3/18/25 at 2:35 PM, V5 (Nurse) said that on 3/9/25 R1 was heard screaming and saying she had burnt herself from her coffee. V5 said that there was a cup of coffee in front of R1 with no lid and a straw in the cup. V5 said that R1's gown was soaked with coffee and her chest from her breast to her neck was with redness. V5 said that she called the doctor and the EMT (emergency medical team). On 3/18/25 at 1:43 PM V3 (Speech Language Pathologist) said he does not recommend anyone drink hot coffee from a straw unsupervised for safety issues. V3 said that staff should have only given R1 sips of hot coffee from a cup without a straw. On 3/18/25 at 2:50 PM, V6 NP (R1's Nurse Practitioner) said that R1 had a swallow study in 2024 and it recommended that R1 not use a straw. V6 said that staff should have been helping R1 drink hot coffee without using the straw. V6 said that if staff had been there, they would have taken the straw away and R1 would not have gotten burned. On 3/18/25 at 4:52 pm V2 DON (Director of Nursing) said that R1 was drinking hot coffee out of a cup with no lid with a straw and was unsupervised. V2 said that if R1 had not been drinking out of a cup with no lid, through a straw, without supervision, R1 would not have gotten burned. V2 said that her expectations are that the staff maintain supervision while drinking hot coffee. On 3/18/25 at 5:10 PM V1 (Administrator) said that R1 should not have been drinking hot coffee out of a straw unsupervised. V1 said that because staff allowed R1 to drink hot coffee with a straw unsupervised it caused her to get 1st and 2nd degree burns to her chest. The facility's Feeding and Assisting Residents to Eat policy dated 1/25 shows that the facility staff shall follow safe practices in feeding or assisting residents during mealtimes. The policy showed that staff may offer a straw if it is not contraindicated.
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