Other·May 25, 2023

F 689 483.25(d) Accidents The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 72523(a) Patient Care Policies and Procedures (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/3/2023 the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) of Resident-to-Resident abuse. On 1/18/2023, at 8:40 a.m., the CDPH made an unannounced visit to the facility to investigate the FRI. While investigating the allegation of resident-to-resident abuse, another resident (Resident 2) was observed with an injury to her right thigh. After investigation into Resident 2’s injury, it was determined that a Certified Nursing Assistant (CNA 1) left a cup of hot water on Resident 2’s overbed table when Resident 2 was sleeping and unaware the hot water was there. The cup of hot water fell over and spilled on Resident 2’s leg causing Resident 2 to sustain a second-degree burn (injury to the first and second layers of skin that causes blistering, shiny skin, pain, and skin discoloration) to her right thigh. The facility failed to: 1. Ensure CNA 1 did not leave an unattended cup of hot water, used to make Resident 2's tea, on Resident 2's overbed table when the resident was not fully awake, without warning Resident 2 of the potential danger of the hot water. 2. Ensure CNA 1 set up Resident 2 's breakfast tray and provided the resident assistance with drinking the hot tea, per the facility's policy and procedure (P/P), titled "Safety and Supervision of Residents." 3. Follow the facility’s P/P, titled “Safety and Supervision of Residents,” that indicated resident supervision is a core component of the facility’s approach to safety by leaving hot water on the resident’s overbed when the resident was not fully awake. As a result of this deficient practice, Resident 2 sustained a second-degree burn and incurred pain to her right thigh, requiring a wound consult and treatment with Silvadene cream (a medicated cream used to treat burns) for seven days. This deficient practice had the potential for continued impairment of Resident 2's skin, pain, and infection. A review of Resident 2's Admission Record (Face Sheet) indicated the facility admitted Resident 2 on 11/26/2022 with diagnoses including dementia (progressive loss of memory), neuralgia (nerve pain), and diabetes ([DM] high blood sugar). A review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 11/30/2022, indicated Resident 2's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 2 had highly impaired vision, was unable to make decisions for herself, and required extensive one-person physical assistance with eating. A review of Resident 2's History and Physical (H&P), dated 11/28/2022, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2's Situational Background Assessment Recommendation ([SBAR] a communication tool between members of health care team about a resident ' s change in condition) dated 1/18/2023, and timed at 11:41 a.m., indicated Resident 2 spilled hot tea on herself, and fluid filled blisters on her right inner thigh developed. A review of Resident 2's Skin Supplemental Assessment (SSA) dated 1/18/2023, and timed at 11:42 a.m., indicated Resident 2 had a fluid filled blister measuring 5.5 centimeters ([cm] a unit of measurement) by 2.8 cm. During an observation on 1/18/2023, at 11:18 a.m., a puddle of water was noted on the floor in Resident 2's room next to her bed. Resident 2 appeared ungroomed, and her clothes and blanket were wet. Resident 2 was screaming and stated she was in pain and hurting as she pointed to her exposed right thigh. Resident 2 stated hot tea spilled on her and she had requested pain medication. Resident 2's right thigh appeared red with diffuse (spread over a large area) blisters and an empty plastic mug was sitting on Resident 2's overbed table, after it spilled on her. During an interview on 1/18/2023, at 12 p.m., CNA 1 stated the breakfast tray with hot tea was provided to Resident 2 around 7:30 a.m. (1/18/2023). CNA 1 stated, Resident 2 was still half asleep when CAN 1 placed the breakfast tray on Resident 2's overbed table that morning. CNA 1 stated Resident 2 could eat on her own, but the tray needed to be set up. During an interview on 1/18/2023, at 1:43 p.m., CNA 1 stated he obtained the hot water that was served to Resident 2 during breakfast from the kitchen. CNA 1 stated Resident 2 liked her tea hot, and Resident 2 would ask for hotter water if she did not think it was hot enough for her. CNA 1 stated Resident 2 would dip her finger into the water to check if the temperature was hot enough for her. CNA 1 stated he was responsible for picking up and setting up Resident 2's tray and the last time he was in Resident 2's room was around 7:40 a.m. (1/18/2023). CNA 1 stated it was not safe to leave hot tea on Resident 2's overbed table when she was not fully awake because Resident 2 might accidentally spill the hot tea on herself and get burned. During a concurrent observation and interview on 1/18/2023, at 1:50 p.m., Cook 1 (CK 1) stated hot water provided to residents comes from the facility’s coffee maker and the temperature of the coffee maker was about 140 to 160 degrees Fahrenheit ([F] a unit of measurement to determine temperature). CK 1 checked the temperature of the hot water in the coffee maker machine, using a thermometer, which showed a reading of 167 degrees F. A review of the facility's coffee maker Service Manual (SM) dated 2/2011, indicated that water in the heating tank will require approximately a half hour before reaching operating temperature of 200 degrees. The SM indicated the temperature is programmable from 170 degrees F to 206 degrees F. During an interview on 1/18/2023, at 3:02 p.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 2 had a second degree burn on her right thigh because of the spilled hot tea (1/18/2023), as verbalized by Resident 2. LVN 2 stated hot water could cause burns and produce blisters and should not be given to a resident who was not fully awake because the resident might spill the hot tea and burn herself. A review of Resident 2's Physician's Order (PO), dated 1/18/2023, indicated to apply Silvadene Cream to Resident 2's right inner thigh two times per day, for seven days, leave it open to air (LOA) and reassess in seven days. A review of Resident 2's Treatment Administration Record (TAR) dated 1/2023, indicated Silvadene cream was applied to Resident 2's right inner thigh twice a day beginning 1/18/2023. A review of Resident 2's Wound Care Consultation Note (WCCN) dated 1/24/2023, indicated Resident 2 had a second degree burn on her right thigh which measured 5.5 cm in length and 2.0 x 2.0 cm in width. During an interview on 1/18/2023, at 3:27 p.m., Registered Nurse Supervisor 1 (RNS 1) stated Resident 2 was confused, was a high risk for falls, and did not always use her call light when she needed assistance. RNS 1 stated it was not acceptable to leave a cup of hot water with a resident who was not fully awake because the resident should be able to hold their cup of hot water to prevent accidents, such as burns, from occurring. RNS 1 stated staff should do frequent rounds on the residents, because most of them were confused. RNS 1 stated everyone was responsible for resident safety and although Resident 2 liked her water hot, all staff members should take precautions because Resident 2 could not decide for herself and process the information or instructions provided to her. During an interview on 1/18/2023, at 4:15 p.m., the Director of Nursing (DON) stated Resident 2's room was close to the nursing station because of her confusion, high risk for falls, and her need for supervision. During an interview on 3/28/2023, at 3:15 p.m., CNA 2 stated Resident 1 needed objects placed close to her to see and grab them. CNA 2 stated Resident 2 had only one eye that opened. A review of the facility's P/P titled, "Safety and Supervision of Residents," revised 7/2017, indicated resident supervision is a core component of the facility's approach to safety. The type and frequency of resident supervision is determined by individual resident's needs and identified hazards in their environment. A review of the facility's P/P titled "Water Temperatures, Safety of," revised 12/2009, indicated direct care staff shall be informed of risk factors for scalding burns that are common in the elderly such as decreased skin thickness, decreased skin sensitivity, peripheral neuropathy (weakness and numbness from nerve damage), reduced reaction time, decreased cognition, decreased mobility, and decreased communication. The length of exposure to warm or hot water, the amount of skin exposed, and the resident's current condition will affect whether exposure to certain temperatures will cause scalding or burns. The Nursing staff will be educated about signs and symptoms of burns so such injuries can be recognized and treated appropriately. The facility failed to: 1. Ensure CNA 1 did not leave an unattended cup of hot water, used to make Resident 2's tea, on Resident 2's overbed table when the resident was not fully awake, without warning Resident 2 of the potential danger of the hot water. 2. Ensure CNA 1 set up Resident 2 's breakfast tray and provided the resident assistance with drinking the hot tea per the facility's P/P, titled "Safety and Supervision of Residents." 3. Follow the facility’s P/P, titled “Safety and Supervision of Residents,” that indicated resident supervision is a core component of the facility’s approach to safety by leaving hot water on the resident’s overbed when the resident was not fully awake. As a result of this deficient practice, Resident 2 sustained a second-degree burn and incurred pain to her right thigh, requiring a wound consult and treatment with Silvadene cream for seven days. This deficient practice had the potential for continued impairment of Resident 2's skin, pain, and infection. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.