**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, Incident Report review, observations, and staff interviews the facility failed to ensure a resident with severely impaired cognition remained free from burns from hot liquid when the resident was found with a cup on their lap during shift change to night shift, resulting in blisters to the left abdomen and thigh and documented pain for one of four residents reviewed for accidents (Resident #7). This resulted in an Immediate Jeopardy (IJ) to the health and safety of a resident who resided at the facility. The facility reported a census of 30 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 1/11/24 at 2:15 PM. The IJ began on 1/1/24. Facility staff removed the Immediate Jeopardy on 1/16/24 at 9:57 AM by completing the following: a. All residents were assessed via the Hot Liquids Safety Evaluation form for safety, when handling hot liquids. b. Any resident found to be at risk for inability to handle hot liquids safely will be placed on a Hot Liquids Safety list. The list will be kept in the Dietary Department and Nursing Department where all staff can visualize. This list will be updated by the Nursing Office. c. All facility staff were educated regarding the Hot Liquid Assessments, the list and where it is kept. d. Audits to be completed to assure staff compliance with the Hot Liquids Safety List will be done at every meal x 7 days, daily x 7 days, weekly x 2 months and then monthly times 2 months. e. Results of all Audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Meeting monthly for any observations and recommendations. The scope lowered from J to D at the time of the survey. Findings Include: 1. The Minimum Data Set, dated [DATE] for Resident #7 revealed the resident was rarely to never understood and required supervision or touching assistance for eating. The Care Plan dated 10/14/22, revision date 12/27/23, for Resident #7 revealed, in part, the following: a. The resident needed assist with Activities of Daily Living (ADL) related to (R/T) a cerebrovascular accident (CVA- stroke) with right sided lower extremity (LE) weakness, right sided upper extremity flaccidness which places the resident at risk for falls/injury. b. The resident not able to eat in the dining room at this time due to there being too much stimulus, causing the resident to yell out and be disruptive to others. c. The resident does eat better in own room or during the week can go into the Activity Room and eat with [Name Redacted] or [Name Redacted] there. Resident likes it in this room, and eats better and stops yelling. d. The Intervention dated 3/4/22 documented to assist the resident with eating by supervising and making sure able to eat the food on own. Sometimes need physical assistance due to having to use left hand. e. The Intervention dated 1/2/24 documented, Intervention for burn/blister: Resident will not be given any hot liquids without supervision and all trays/hot liquids will be removed from room when staff leaves room or family leaves room. Resident is to be up to dining room if possible for all meals. The Diet Order 3/14/22 documented, Mechanical soft diet, Ground meat texture. Review of the resident's Nutrition Quarterly assessment dated [DATE] revealed the following per the ability to feed self-section: feeds self with supervision and cueing, and the current mental status section revealed, severe impairment. The Incident Report dated 1/1/24 at 10:30 PM for Resident #7 documented the following Incident Description Nursing Description: Third shift Certified Nursing Assistant (CNA) alerted Staffing Nurse about areas on left abdomen and thigh. Appears to be blistered areas with redness around blisters. Cup removed from lap before transferring to bed, with what appeared to be coffee in it cold at this time. The Resident Description documented, Unable to state what happened. The Immediate Action Taken Section documented, Resident cleaned per CNA and made comfortable in bed. CNA notified this nurse also by text of issues. CNA stated nurse came down measured areas and applied cool wash cloth. The Injuries Observed at Time of Incident Section documented abdomen and left thigh. The Mental Status Section documented Resident #7 alert to person. Predisposing Physiological Factors marked included the following for the resident: Confused, drowsy, incontinent, impaired memory, recent change in cognition, and weakness/fainted. The Other Info Section of the Incident Report documented, Resident was left with supper tray in room in reach and coffee was on tray which was spilled into lap. Due to dementia and issues with coordination resident is to be supervised with meals. The Nurses Note dated 1/1/24 at 10:44 PM documented, resident was found to have blisters on lower left abdomen and left upper thigh area. two blisters present on abdomen. one blister present on upper thigh area. no complaints of (C/O) of pain at this time. Blisters maybe caused by hot food spilling on the resident. The Progress Note authored by the Assistant Director of Nursing (ADON) dated 1/2/2024 10:18 AM documented, was reported to this nurse through text on 1/1/2023 that resident was found sitting in recliner with food tray and cup on her lap. When assisted to bed CNA noted that resident had redness and blisters to left thigh and abdomen. Called nurse to room who placed cool cloth on areas and measured areas. Daughter was notified this AM along with [Name Redacted] Advanced Registered Nurse Practitioner (ARNP) and Hospice. Review of the Visit Note Report from Hospice dated 1/2/24 documented the following Chief Complaint/Problem: Patient (Pt) has burns/blister from spilling coffee on her last night. The Assessment Section documented, Pt has fluid filled vesicles on the left upper thigh and left lower abdominal quadrant. The Assessment documented, Speech is unclear. Pt can occasionally get something simple like Yes No or Out spoken, and also documented, Cognitive decline interferes with Pt's ability to express pain, rate pain, characterize pain. The Visit Note Report dated 1/2/24 documented the following wound descriptions: a. Wound #1: The resident had a left proximal thigh burn, onset date 1/1/24, documented as 5 centimeters (cm) length by 2 cm depth by 0 cm depth. The Wound Care Provided Section documented, Large blister intact with clear/yellow colored fluid. There is an area of redness surrounding. Unable to determine of area is painful or if Pt just refusing care as she is refusing all assessment. b. Wound #2: Burn to the abdominal left lower quadrant, onset date 1/1/24, documented as 5 cm by 8 cm by 0 cm. The Wound Care Provided Section documented, there are 3 separate blistered areas. Pt resistive to assessment and only able to get a rough measurement of the cluster of blisters versus each individual blister. There is redness surrounding the wound. Pt would not allow measurement of the redness. Unable to determine if the area is painful as Pt was resistive and uncooperative with assessment in general. The Narrative for the Visit Note Report dated 1/2/24, documented, in part, as needed (PRN) visit completed due to (D/T) Pt spilling coffee on herself last night causing redness and blistered areas on the left lower abdomen and left upper thigh. There is one fluid filled/intact blister on the left thigh and 3 fluid filled/intact blisters on the left lower abdomen. There are areas of redness surrounding these areas. Review of a Quality Monitoring/Performance Improvement Plan (PIP) dated 1/2/24 documented, Resident received burn from coffee. The Corrective Action Section of the form documented corrective action was needed, and revealed, in part, the following: a. A CNA from [Agency Name]-lied to [Facility Name] staff when they asked her how Resident #7 ate. She stated she ate good. In fact, it appears she did not check on her. CNA no longer able to come to facility. b. Nurse from [Agency Name]-Appears she did not check on Resident #7 in person as Resident #7 not gotten ready for bed appropriately. This nurse no longer will be allowed to work at [Facility Name]. The Physician Order dated 1/2/24 at 11:00 AM documented: cleanse left abdomen and left thigh gently with soap and water. Pat dry apply Xeroform Vaseline gauze to areas. Change daily and PRN. Check every shift to make sure dressing is in place to burn/blister. One time a day for wound healing discontinue (DC) when healed and as needed for wound healing and every shift for wound healing. Check to make sure Xeroform is in place. Review of the resident's Treatment Administration Record (TAR) dated January 2024 revealed treatment initiated 1/2/24. The Nurses Note dated 1/2/24 at 6:48 AM documented: Skin sheet done on resident for blisters on upper left thigh and lower left abdomen. Multiple blisters noted on abdomen. Blisters are fluid filled with redness noted around the blister. Skin was warm to the touch and it was noted that the blisters were uncomfortable/painful for resident. ADON/skin nurse notified. Hospice called and notified of burns to skin. The Notes Section of the Incident Report dated 1/2/24 documented the following: a. Resident will not be given any hot liquids without supervision and all trays/hot liquids will be removed from room when staff leaves room or family leaves room. Resident is to be up to dining room if possible for all meals. b. Have spoken to CNA'S and Nurses personally and had them sign regarding not leaving before they do a physical round (eye balling) each resident even the ones that they are not directly responsible for to see if anything needs done. c. [Staff G, CNA] the CNA from staffing will not be allowed back into the facility due to her lying to a staff CNA about resident eating fine and no issues. (resident was not fed by CNA and tray was left in room) d. It was reported that Resident #7 spilled her ice water on her that was in a sippy cup. Her gown was completely wet and the linens all had to be changed. Staff is being educated to of course not give hot or warm fluids at all and visually check on Resident #7 every two hours at minimum. e. Dietary Aide stated coffee was served to Resident's room tray in a lidded cup. [NAME] states at approximately 7:10 pm while passing evening (HS) Snacks she did not witness any coffee cup on Resident's lap but that she wasn't looking for it. Food tray was not on her lap at that time, nor did resident show any signs of discomfort or pain, Dietary staff have been instructed not to serve Resident any hot beverages and that Resident will no longer be a room tray but will be seated in the dining room with assistance with eating. The Nurses Note dated 1/4/24 at 5:24 AM documented, in part, dressing completed to left lower abdomen and left upper thigh. 2 large clear fluid filled blisters present to abdomen wound. Areas cleansed, dried, applied Xeroform gauze et covered per orders. Facial grimacing noted during dressing change, resident continued to push this nurse's hands away while applying the dressings. The Note dated 1/9/24 on the Incident Report documented, Summary: Staff did not know how Resident #7 even got coffee on her super tray until all staff input made it clear Resident #7 nods her head yes to most everything. The CNA that took her supper ticket to the kitchen did not know this information. This is why no temporary staff will be on any halls by themselves until oriented a minimum of 8 hours. All residents have had an evaluation for hot liquids done, the list of residents that should not get hot liquids in their rooms or without 1:1 supervision will be kept in the kitchen and the Care Plans updated. Resident #7 will no longer receive hot liquids even with 1:1 due to pouring ice water on her head even while her daughter was sitting next to her. The Alert Note dated 1/9/24 at 10:39 AM documented, Skin Note: Blister to left thigh is scabbed as this is where she has peeled the skin off of. Area is 6 cm across by 4.5 cm. Area was cleansed and new dressing applied no signs/symptoms (S/S) of pain with this. Left abdomen has one boomerang shaped area measures 6 cm by 5 cm and 5 cm by 3 cm with epithelial tissue present as she did not peel skin off of this, no S/S of infection. Smaller 2 cm by 1 cm area to inner left abdomen. No S/S of infection to any areas. No complaints of (C/O) pain with cleansing or treatment change. On 1/10/24 at 1:14 PM, Staff F, Registered Nurse (RN) explained eating assistance required for Resident #7 depended on the day, and some days the resident was fine and able to do herself. Staff F explained the resident often refused help. Per Staff F, they offered more than one person to assist, the resident ate in the dining room, and ate in her room if her daughters at the facility. Staff F explained she did not let the resident stay in her room because Staff F liked to watch her. The Nurses Note dated 1/10/24 at 2:25 PM documented, Resident remains on Hospice [Company Name Redacted] cares. No noted behaviors this shift. See Nursing Note about eating. Blisters are open and draining. Blister on thigh is red with slough. On 1/10/24 at 3:15 PM, interview with Staff D, CNA revealed the following: Per Staff D, Resident #7 usually ate on her own really, did not use utensils, and used her fingers. Staff D explained if the resident ate in her room someone always supposed to be in to help and the resident no longer got coffee unless someone assisted. Staff D explained need to cue the resident if the resident falling asleep, and further explained the resident ate with her fingers pretty good. Per Staff D, if Resident #7 was too weak sometimes, then the resident did not want to get up. Per Staff D if the resident did not have energy, they would go in and feed Resident #7. Staff D explained for the most part the resident did really good. The Nurses Note dated 1/10/24 at 8:49 PM documented, no noted behaviors, blisters on wound on thigh is red around the boarder with white slough on the center of the wounds. Wound on stomach is red around the board no noted slough. Ate supper with assistance from staff. On 1/11/24 at 8:45 AM, the ADON explained the Night Shift Nurse had been a staffing nurse, and the ADON received a call from the Night Shift Aide on behalf of Staff I, Licensed Practical Nurse (LPN), Staffing Nurse. The ADON explained they (ADON) filled out the incident report. Per the ADON, Staff G, staffing CNA worked with Resident #7 that night. The ADON explained she received a call from a facility CNA (3rd shift), Staff J, CNA. On 1/11/24 at 8:50 AM, observation revealed Resident #7 in their room in their recliner chair. Observation of wound care to the resident's thigh conducted with Staff H, Hospice Registered Nurse (RN). An area observed to the left thigh with yellow wound bed and redness around wound bed. Staff H explained the following about the area to the resident's left thigh: The last time Staff H saw the area, skin was covering, and now it was yellow with red around. Per Staff H, the area was much worse than when she last saw it. Per Staff H, the resident picked at the blister. Staff H explained she would call the doctor about an antibiotic cream. Staff H explained the area had to hurt, and acknowledged it came from coffee. Review of the Visit Note Report from dated 1/11/24 revealed the following wound description for Wound #1: The resident's left proximal thigh wound: The measurement section documented 6 cm by 4.5 cm by 0.2 cm, depth description noted full thick, with scant purulent drainage. The Narrative Section of the Visit Note Report documented, in part, Performed her wound dressing change on her thigh. It does appear infected, reached out to [Name Redacted] Nurse Practitioner (NP) for orders, awaiting her return call with new orders. Wounds on abdomen do not appear infected at this time. On 1/11/24 at 11:57 AM, interview conducted with Staff J, CNA, who explained the following about the incident: Staff J explained she worked nights, did not remember the incident date, and came in on nights at approximately 9:45 PM with another staff member (Staff K, CNA). Staff J explained the nurse for her shift was a Staffing Nurse, and explained on second shift a Staffing Nurse and Staffing Aide present when she came in. Per Staff J, the Staffing Aide (on the shift prior) had never worked at the building before, and had been in charge of South Hall where Resident #7 resided. Staff J explained the other two staff who worked with the Staffing Aide were facility staff. Staff J explained the Staffing Aide floated and helped. Staff J explained in getting report from the Staffing CNA, the Staffing CNA said she had never been in the facility before and was not able to tell Staff J much. Staff J explained when Staff J got to the facility a couple people were up in the dining room, and Staff K went ahead and started walking the halls. Staff J further explained Staff K said there were a lot of people up, and Staff J explained at that point it was easier to let the Staffing CNA go. Staff J and Staff K started a round, and offered to see if anybody wanted to go to bed. Staff J explained since the Staffing CNA had been on the South hall, they went ahead and started the round on South hall right after 10:00 PM. Staff J explained Resident #7 was the first person they addressed on the South hall. Per Staff J, she and Staff K went in and Resident #7 was still in the recliner, which Staff J explained had never happened as the resident was always in bed when she got to the facility. Staff J explained Resident #7's blanket was peeled back, underneath the resident wore blue snap pants, and there was a puddle around the resident's pants, dark, brown, and dried. Staff J explained it was like the second shift aides had not touched the resident since first shift put the resident in the recliner before they left. Per Staff J, the resident was so soaked her brief had seeped through. Staff J explained the resident's tray was on top of her on her lap. Per Staff J, the resident was known for that to pull things down on her. Staff J explained the resident was Care Planned to have a soda on the side of the bed and would pick it up and dump on herself. Per Staff J, the resident was not safe to have hot liquids in her room. When queried how this information was communicated prior to the incident, Staff J responded common sense, and if spilling soda pop on her, then wouldn't put coffee. Per Staff J, if Staffing (Agency) staff were not shown, then they did not know, and the facility had more Staffing (Agency Staff) in the facility than regular people. Staff J explained the resident had regular dishes, the tray itself was still on the nightstand, the only thing on the tray was the tray and plate, and everything else was in her lap (cups/bowl). Staff J explained maybe the brown ring in her lap could have been coffee, and she and the other staff member thought urine because the resident was soaked through the back. Per Staff J, she and Staff K took everything off the resident's lap and set it on the nightstand, used the Hoyer (mechanical lift) to get the resident to the bed, cleaned the resident up, took the resident's pants down, and realized the resident had started to blister on the left bottom part of the resident's abdomen and one spot on her top part of her thigh. Staff J explained it was all red all around and yellow/bubbly. Staff J explained when she and Staff K started rounding she told the Staffing Nurse to keep an eye on the hall as they were going to be busy for a while. Staff K explained the Staffing Nurse was down taking care of another resident, she waited for the nurse for a few minutes, the nurse looked at Resident #7, and said yeah it has to be a burn for sure. Staff J explained the resident was given a bed bath, cleaned up, the nurse came in and did measurements, and hourly checks were done after that. On 1/11/24 at 3:27 PM interview conducted with Staff I, Licensed Practical Nurse (LPN), who explained they worked the day after the incident, came in at 10 PM (on 1/2/24) to 6 AM (on 1/3/24). Per Staff I, she came in on her shift, received report, and was told there were blisters on the Resident #7's left leg and left side of her lower abdomen. Staff I explained she knew they were from a hot liquid. When queried about symptoms of pain for the resident, Staff I said yes, and explained just applying the dressing around the area the resident flinched and was very cautious. Staff I explained she could tell it was painful. Per Staff I, prior to the incident that resident had to have the special cups with sippy type device to hold onto it, and explained the resident did sit at the assisted table on a regular basis. Staff I explained sometimes the resident wanted your help and also very independent wanted to do herself. Staff I explained assistance was more supervisory. The Physician Order for Resident #7 dated 1/12/24 documented, Cefadroxil Oral Suspension Reconstituted 250 MG/5 ML (milligram/milliliter) with instruction to give 5 ml by mouth every 12 hours for infection for 7 Days. On 1/16/23 at 912 AM, Staff F, Registered Nurse (RN) explained Resident #7 started on antibiotic for the thigh area, as worried about infection as the resident liked to pick at it. On 1/16/24 at 1:28 PM, Staff N, LPN acknowledged she did work 1/1/24 (date of incident). Staff N explained she got to the facility at 8 PM to 6 AM, explained she had worked for the facility as a CNA, and came in at 8 PM for training. Staff N explained when the overnight staff came in at 10:00 PM or 10:30 PM, the aides came in and said it looked like spilt food all over the resident. Staff N explained getting the resident laid down, and had blisters to the lower left abdomen and left upper thigh. Per Staff N, a cool washcloth applied, and she call the ADON to let her know. Staff N further explained Resident #7 sat in the recliner, and staff called her in to see food spilt all over. Per Staff N, the blisters were noticed once got the resident into the bed. Staff N was unable to recall the names of the aides. When queried if the resident spoke, Staff N explained the resident did not really talk to her. Staff N explained she asked the resident if in pain, and the resident shook her head no. On 1/16/24 at 1:33 PM when queried if she worked the night of the incident, Staff O, Medication Aide/CNA explained she thought so, and later clarified she did. Per Staff O, she did not normally go down that hall (where Resident #7 resided) and did meds on two other halls. Staff O explained she knew there was a Staffing CNA that night who had passed the trays on the hall where Resident #7 resided. Per Staff O, she saw the CNA take the cart, and didn't see the staff member actually pass the trays. Staff O explained she knew the resident had been getting room trays or eating down with family in her room and before the incident she was not aware of the resident spilling drinks on herself. On 1/16/24 at 2:48 PM, Staff P, CNA explained she worked 4 PM to 8 PM on the date of incident (1/1/24). Per Staff P, an agency staff was working the hallway and it was the agency staff's first time at the facility. Staff P explained the agency staff passed trays, and had Resident #7 and another resident eating in their rooms. Per Staff P, after dinner she had seen the staff member coming towards the kitchen with a tray, which made Staff P think of Resident #7 as the resident did not always eat in her room and if Resident #7 was not hungry she would not eat it. Staff P explained it made Staff P ask the Agency Staff, and the Agency Staff reported Resident #7 ate everything. Staff P explained she was very busy before 8:00 PM, had four residents up, and passed on that she had not helped the Agency Staff member with Resident #7 or another resident yet, and explained those residents required assistance of Hoyer transfer. Staff P explained she did not come back down to check herself, and took the Agency Staff member's word for it when the staff said the resident ate everything. When queried if Resident #7 could eat in their room by themselves prior to the incident, Staff P responded yes, and further explained sometimes with medication the resident got sleepy, and when she ate in her room Staff P would wake her up and let her know food was there. Per Staff P, prior to the incident, the resident drank a lot of coffee, at least for dinner, and for the most part ate in the dining room. On 1/22/24 at 12:53 PM, when queried if the facility had a way to assess residents for hot liquids prior to the incident, the Interim Director of Nursing (DON) explained not that she was aware of. When queried if the resident was known to dump fluids on herself prior to the incident, the Interim DON responded no, and as long as the Interim DON had been at the facility the resident would drink cans of soda in her room, and would not dump that on herself. When queried where the resident ate, the Interim DON explained since she started at the facility the resident almost always ate in the dining room. Per the Interim DON the resident used to feed herself, and over the last six months the resident slowly started to not want to eat, and the resident needed cueing. Per the Interim DON, sometimes the resident would let you scoop food on her spoon for her, and wanted you to leave it. When queried how often CNA's and nurses rounded on the resident, the Interim DON explained normally the resident should be ok for every 2 hours. Per the Interim DON, they had not seen the resident drink hot liquids, and usually at night the resident drank water or soda, and when she would work days saw her drink orange juice or water in the morning. On 1/22/24 at 4:25 PM, the Interim DON provided an undated form titled Hot Liquids Safety Evaluation, and explained to be included with the plan of correction. The form documented, Directions to be completed at time of admission, readmission or change in condition: (1) Evaluate for the presence of risk factors for spills and burns from hot liquids. (2) Place a check mark for each risk factor in space provided for that evaluation date. (3) Initial and sign the evaluation. (4) Review evaluation during care team meeting to determine appropriate interventions to prevent spills and burns. (5) Record date intervention was initiated, notes and date it was discontinued (if applicable).