| 11563 |
REGENCY SQUARE CARE CENTER |
285076 |
3501 DAKOTA AVENUE |
SOUTH SIOUX CITY |
NE |
68776 |
2012-01-24 |
323 |
J |
1 |
0 |
8SG711 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D7b Based on record reviews, observations, and staff interviews; the facility failed to assess residents' risk for burns from hot liquids and implement interventions to prevent burns from spilling hot liquids for 2 residents (Resident 1 and 3) of 5 sampled residents. The facility identified a total of 15 residents at risk for burns from hot liquid out of a total census of 61 residents. Findings are: A. On 1/9/12 at 12:50 PM, a cup of coffee was obtained from facility coffee machine in dining room of the facility. Coffee was poured into a thermal cup that the facility utilized to serve to coffee to residents of the facility. The following temperatures were recorded from facility thermometer in the presence of the Dietary Manager: -12:50 PM, just poured, 165 degrees Fahrenheit (F) -12:55 PM 156 degrees F -1 PM 144 degrees F -1:05 PM 138 degrees F -1:10 PM, 20 minutes after coffee was poured, 132 degrees F In an interview on 1/9/12 between 12:05-12:30 PM, the Dietary Manger reported the coffee machine temperature was set at 175 degrees F with coffee to be between 160-165 degrees F when poured into a cup. The coffee machine had been installed at the facility in 11/11 according to the Dietary Manager. In a follow-up interview on 1/10/12 at 8 AM, the Dietary Manager reported the facility started using the thermal cups at the about the same time as the facility installed the new coffee machine due to receiving complaints about the coffee being cold. A review of Equipment Service Invoice revealed coffee machine was installed on 11/17/11. Observations in the dining room at 2 PM on 1/9/12 revealed the coffee was on and accessible to residents. A visitor but no staff members or residents were observed in the dining room. In an interview on 1/10/12 at 8 AM, the Dietary Manager confirmed the coffee machine was on and coffee was available in the dining room at all times. B. Resident 1 was admitted to the facility on [DATE] according to Record of Admission. Resident 1's Client [DIAGNOSES REDACTED]. A review of Resident 1's MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 11/9/11 revealed the following: -Resident 1 scored 12 out of 15 points on Brief Interview for Mental Status (BIMS). -Resident 1 required supervision and setup assistance for eating Resident 1's Care Plan did not include a problem related to burns for spilled hot liquids but did include the following interventions related to potential hot liquid burns. -Resident 1 to have all meals in dining room. -Offer Resident 1 a clothing protector at each meal. Resident 1 wants a clothing protector at times. -Cool coffee with water before serving to Resident 1 (This intervention was dated 1/5/12. 5 days after Resident 1 sustained a burn from spilling hot coffee.) Therapy Screen Form for Resident 1 dated 11/21/11 stated "Nursing reports decrease function, increased frequency of falling, only eating 25%, no longer ambulating to dine." The Therapy Screen Form concluded therapy evaluation indicated for occupational therapy, physical therapy, and speech therapy. physician's orders [REDACTED]. Incident Report for Resident 1 for incident on 12/31/11 at 5 PM stated the following: "Resident was sitting at the table in the dining room waiting for supper when this med (medication) aide notice resident spilled (Resident 1) hot coffee on (Resident 1) lap. CNA (Certified Nurse Aide) and med aide took resident to (Resident 1) room. Notice redness on both thighs cool rag was applied." Non-Decubitus Skin Conditions report form for Resident 1 dated 12/31/11 identified a large blister on left inner thigh and 2-3 larger blister and several smaller blisters on right thigh. A review of physician's orders [REDACTED]. -1/1/12 Slivadene cream to blisters twice a day cover with dressing -1/3/12 Cephalexin (an antibiotic) 500 mg caps 1 orally three times per day for 10 days Non-Decubitus Skin Conditions report entry for Resident 1 dated 1/10/12 identified the following: -Area A-Resident 1's left thigh had 4 cm (centimeter) x .7 cm drying blister linear, yellow/greenish in color with no dressing, no periwound redness, no odor, and no warmth. -Area B-Resident 1's right thigh had 12.5 cm x 2 cm linear areas with bridging present. Area has 50% dry intact blister and 50% moist yellow with red flecks. -Area C-Resident 1's right thigh had 9.5 cm x 1.7 cm linear drying blister, with no warmth, no periwound odors, or drainage. Observation of and interview with Dietary Manager at 5:35 PM on 1/9/12 revealed Resident 1's coffee was cooled with water prior to service to Resident 1. Observations at 7:30 AM on 1/10/12 revealed Resident 1's coffee cooled with ice prior to service. A check of coffee temperature for coffee prepared for Resident 1 revealed a temperature of 65 degrees. A review of Resident 1's medical record did not reveal an assessment for safety with hot liquids. C. Resident 3 was admitted to the facility on [DATE] according to Record of Admission. Resident 3's Client [DIAGNOSES REDACTED]. A review of Resident 3's 12/7/11 MDS revealed the following: -Resident 3 scored 14 out of 15 on BIMS. -Resident 3 required extensive assist of one person with eating. Resident 3's Care Plan, dated 10/8/09, identified Resident 3 as eating slow and needing assist with meals. The intervention listed related to potential for spilling hot liquid was assist (Resident 3) with clothing protector for all meals per (Resident 3) request." Observations between 12:45 PM-12:56 PM on 1/9/12 revealed Resident 3 at the table in the dining room. Resident 3 was served a cup of coffee from the coffee machine with powdered creamer mixed into it. The coffee cup had no lid and a straw was placed into the cup of coffee. Resident 3 was observed with head tilted back holding cup of coffee at an angle drinking coffee from the straw. No staff members were observed to assist Resident 3 or be present at Resident 3's table at the time Resident 3 was drinking the coffee. Observations between 5-5:15 PM on 1/9/12 revealed Resident 3 being fed pureed food. Resident 3 was observed to drink pink liquid from a glass independently and spill pink liquid onto Resident 3's clothing protector. Hot Liquids Safety Evaluation dated 1/10/12, after observation of Resident 3 drinking hot liquid independently, identified Resident 3 as being at risk for injury from spills of hot liquids due to contractures of fingers/hands/wrists/elbows or shoulders and loss of mobility/reduced movement in upper extremities. New interventions to be implemented on 1/10/12 due to the evaluation included: temperature of hot liquid not to exceed 180 degrees; hot liquids drank while sitting at table only; coffee cooled with cream; wear clothing protector/lap protector; staff to assist resident with all hot liquids and resident to be seated at an assisted table. D. In an interview on 1/9/12 at 2:50 PM, the ADON reported the facility did not screen residents for safety with hot liquids. In an interview on 1/9/2012 at 3:50 PM, the DON (Director of Nursing) reported the facility did not screen residents for safety with hot liquids but that therapy did screen all new residents at the facility. In an interview on 1/9/12 at 4:12 PM, PTA (Physical Therapy Assistant) Therapy Department Head reported therapy did not do an evaluation of resident's safety with hot liquids. A review of the facility investigation revealed in-service education regarding first aide for burns would be provided to nurse aides on 1/5/12 and nurses on 1/12/12. The facility investigation stated Dietary Staff would be educated as well. In an interview on 1/9/12 at 3:50 PM, the DON confirmed an in-service would be held regarding burns on 1/12/12 for nurses. In an interview on 1/9/12 at 4 PM, the Dietary Manager reported Dietary staff would be attending an in-service regarding burn on 1/12/12. E. The following interventions were implemented by the facility on 1/10/12 to abate the immediacy of the situation and protect residents from hot liquid burns: -The coffee machine located in the dining room was shut off and no coffee was served at the lunch meal on 1/10/12. -A Hot Liquids Safety Evaluation was completed on all residents of the facility with 15 residents being identified at risk for injury from spills of hot liquids. The care plans for the 15 residents identified at risk for injury from spills of hot liquids were updated to include interventions to protect residents from injuries related to spills of hot liquids. -Staff education with an in-service at 2 PM on 1/10/12 was completed. -A list of Residents at Risk with Hot Liquids was posted in the kitchen. The following additional interventions were planned: -Coffee Machine would be moved into the kitchen where only kitchen staff would have access to it. -Lap pads were to be made available for residents at risk. -All staff members were required to read and sign "Hot Liquid Safety Guidelines" prior to staff working. -Coffee for residents at risk for injuries from hot liquids would be poured in to a carafe and cooled to a temperature between 120-140 degrees F before service to residents. |
2015-05-01 |