HospitalInspections.org

Based on review of records and interview, the hospital failed to ensure that 1 of 1 patient (Patient #1) received care in a safe setting on 02/10/10 in that the hospital used a coffee pot with a temperature that could not be regulated.

Findings:
Patient #1's Medical Record included a nursing note dated 02/10/10 that indicated Patient #1 was sitting in the chair in the dining room...spilt her coffee in her lap..." Patient #1 had a reddened area to right "forearm, abdomen, bilateral thighs and peri area..." The physician was notified and Silvadene applied to the "burn areas."

During an interview the morning of 09/01/10, the Director of Plant Operations (Personnel #8) was asked if he remembered an incident involving the spilling of coffee on a patient. Personnel #8 stated that he did check the coffee pot, but there was no way to regulate the temperature. The coffee pot was removed immediately.

The hospital's "Patient's Bill of Rights" (MR# 08039GP 09/08) signed by Patient #1 (undated) noted, "You have the right to a clean and humane environment in which you are protected from harm..."

Based on review of records and interview, the hospital failed to track an adverse quality indicator for 1 of 1 patient (Patient #1) who sustained a burn from a coffee spill on 02/10/2010. The information was not included in the Quality Improvement department's monthly tracked data of adverse events for 02/2010.

Findings:
Patient #1's Medical Record included a nursing note dated 02/10/10 that indicated Patient #1 was sitting in the chair in the dining room...spilt her coffee in her lap..." Patient #1 had a reddened area to right "forearm, abdomen, bilateral thighs and peri area..." The physician was notified and Silvadene applied to the "burn areas."

The "Patient Safety/EOC Committee Meeting" 03/04/10 minutes included documentation of hospital incidents from 02/2010. There was no documentation of an incident that included burns to a patient from a coffee spill.

During an interview the afternoon of 08/31/10, the Risk Manager (Personnel #10) was asked if Patient #1's coffee spill incident was tracked in the monthly Quality Improvement data. Personnel #10 said that it was not part of the reported data.