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Based on observation, interview and record review, the facility failed to:
- provide a safe environment by neglecting to monitor hot beverage temperatures, resulting in 4 patients sustaining burn injuries (patients #10, #13, #14, #15) since January 19, 2014. (A-0144)
-inform 1 of 1 patient's representative (patient #13's) of the extent of burn injuries and follow-up care needed post-discharge, resulting in increased risk of all patient representatives being deprived of information needed to participate in treatment planning. (A-0131)

Based on interview and record review, the facility failed to provide the representative of 1 of 1 patients who sustained a burn injury (#13) with information on the patient's wound assessments during hospitalization and a Plastic Surgery consultation with post-discharge treatment recommendations, resulting in increased risk of poor health outcomes for all patients with representatives. Findings include:

On 4/3/14 from 0900 to 1600, a review of Patient #13's clinical record revealed a signed and executed Durable Power of Attorney for Health Care document. At admission, the patient's Power of Attorney for Health Care signed consent forms for treatment of patient #13. Patient #13 record revealed a diagnosis of dementia and contained daily documentation of impaired mental status during hospitalization.

No documentation of patient #13's Power of Attorney for Heath Care being notified of the patient's burn on 1/20/14 was found. Documentation of wound updates being provided to the patient's representative during hospitalization were not found. A January 29, 2014 Plastic Surgery Consult by Dr. P. states: "I would like to re-evaluate the patient in 1 week (post-discharge)." No documentation stating that the patient's Health Care Power of Attorney was informed of the severity of the patient's burns or the need for an appointment with Plastic Surgery post-discharge was found. The "Patient Instructions" portion of the Discharge Summary provided for review was dated 1/31/14. (The patient was discharged 1/30/14.) No appointments for follow-up with a Plastic Surgeon were listed under "Your Appointments." These findings were verified by staff D on April 3, 2014 at approximately 1600.

Based on observation, record review and interview the facility failed to to protect 4 of 4 patients (#13, #10, #14 and #15) from burns from hot liquid beverages resulting in four patients receiving burns. Findings include:
Observations:
On April 3, 2014 from 0950-1030 observations were made in three unit kitchens, on floors 5, 6 and 7, where hot beverages for patient use are dispensed. A poster, titled "N.O.B.U.R.N." was observed posted near hot beverage dispensers. The poster states: "A safe temperature for hot beverages in the hospital is 130-140 degrees F." On April 3, 2014 at approximately 1000 the Director of Inpatient Nursing stated that this is the hospital's policy. Thermometers for checking hot water temperatures were not available on floors 5, 6 and 7.

On April 3, 2014 from 0950-1030 hot beverage temperatures on three unit kitchens, with coffee makers and hot water spigots (Insta-Hot brand) for patient beverages were tested by the Supervisor of Operations. The following temperatures of hot liquids available for patient beverages on floors 7, 5 and 6 were observed:
--At 0950 on the 7th Floor, coffee was dispensed at 161.2 F. (degrees Fahrenheit) and hot water was dispensed from the Insta-Hot dispenser at 153.5 F.167.9 F.
--At 1000 on the 5th Floor, coffee was dispensed at 167.9 degrees F. and hot water was dispensed from Insta-Hot at 144.1 F.
-- At 1015 on the 6th Floor, coffee was dispensed at 176.5 F and hot water was dispensed from Insta-Hot at 128.5 F.
All observations (above) were verified by the Director or Inpatient Nursing and Supervisor of Operations on April 3, 2014 from 0950-1030.

Record Review:
On 4/4/14 between 0900 and 1600 the medical record for Patient #13 was reviewed and revealed the following: the patient was scalded by a carafe of a hot beverage left at her bedside on January 20, 2014. On January 20 at 0730 and 1600 patient #13's nurse, staff Q, documented that the patient was "A & O x 1-2" (alert and oriented in 1-2 spheres) and "confused." Patient #13 sustained burns on the right lower back and right buttock, according to a physician's note by Dr. R., on 1/20/14 at 1820. Dr. R. diagnosed 2nd degree burns and ordered that Silvadene Cream be applied to the burns twice daily. Dr. R. stated that patient #13 was "A & O x 1." A January 20, 2014 (post-incident) "Nursing Note" by staff Q documented: "burns to RUE (right upper extremity) and R (right) thigh." On 1/29/14 a Plastic Surgery Consultant by staff P stated, "The patient has a burn injury involving the right back, buttock and right upper thigh, lateral aspect, consistent with having spilled a hot liquid with some pooling in that dependent area." Dr. P described the wound as: "possibly full thickness in areas."

Interviews:
On April 3, 2014 at 0930 the Supervisor of Clinical Nutrition stated: "hot water temperatures leaving the kitchen are not being monitored on a regular basis." On April 3 at approximately 1140 the Supervisor of Operations (staff I) stated that the most recent monitoring did not show that patient hot beverage temperatures within range (per policy, 130-140 degrees) on all units and that beverage temperatures were not being monitored and documented on a routine basis.


29955

On April 3, 2014 at approximately 1000 a review of facility's complaint and grievance log for the past six months from October 1, 2013 to March 31, 2014 occurred. The focus of the review was occurrences in relation to patient rights and nursing services. A review of the facility's adverse occurrence and sentinel event log was conducted on April 2, 2014 at approximately 1340. On April 3, 2014 at approximately 1000 during a review of the adverse event and sentinel event log, four events of patient burns were identified and had occurred as follows: January 19, 2014, January 20, 2014, January 24, 2014, and February 2, 2014. The complainant's burn was identified through the review of the events. Patients' who sustained burns medical charts were requested for review. During review of the four charts it was found that all patient burns had occurred as a result of hot beverages being left at the bedside for patient consumption. Patient #10 sustained burns on January 19, 2014 to the abdomen from a carafe of hot water left at the bedside. The patient (#10) was seen by the house physician on January 19, 2014 and treatment for the burned area was ordered. Patient #13 was burned on January 20, 2014 from a carafe of hot water being left at the bedside. Patient #13 sustained burns on her left hand, right thigh, back and buttock. The house physician saw (patient #13) on January 20, 2014 at 1848. Treatment was ordered and a consult for a plastic surgeon was ordered. According to the documentation the patient (#13) was released to an extended care facility and her wounds became infected requiring hospitalization. The patient (#13) required debridement and skin graft surgery. Patient #14 was burned on January 24, 2014 from a cup of hot water being left at the patient ' s bedside. The patient (#14) was seen by the house physician on January 24, 2014. The patient sustained burns to the left thigh and scrotum. A consult for the wound care nurse was ordered on January 24, 2014 but the patient was not seen by the wound care nurse before discharge as the patient was discharged prior to the wound care nurse being able to see the patient. On February 2, 2014 patient #15 sustained a burn from a hot carafe of water being left at the patient ' s bedside. The patient sustained burns to her left outer leg. The patient (#15) was seen by the house physician on February 2, 2014. The patient was seen by the wound care nurse for treatment on February 3, 2014. The patient (#15) subsequently transferred to the rehabilitation unit where she was followed and cared for by the wound care nurse. Patient #15 was scheduled to see a plastic surgeon three weeks from March 12, 2014.

On April 2, 2014 at approximately 1545 a review of the root cause analysis of the patient burn events occurred. On January 30, 2014 a committee was established to address the identified problem of patients receiving burns as a result of hot liquids being served for consumption. The committee established criteria of assessing patients at risk for potential harm from hot liquids being served at the bedside. Patients identified as being at risk for injury included those without the dexterity or strength to prepare their own tea or hot chocolate, patients with limited range of motion, those of advanced age, limited range of motion, and/or cognitive decline. All "Instahot" (levers controlling dispensing of hot water) levers were removed from coffee dispensers on the units and a schedule of checking the temperatures was developed. Education for all nursing staff and dietary staff was to be conducted. During a review of temperature check logs it was discovered temperature checks had not been conducted or documented on patient beverages as planned. During review of the educational material the facility was unable to provide evidence regarding which staff attended or completed the training in order to determine which staff members had received education.

On April 3, 2014 at approximately 1420 an interview was conducted with staff B and staff C. The question was asked if initiatives to prevent burns stated in the "NO BURN" committee plans had been implemented specifically, the use of "no hot beverages" option for dietary orders and the use of magnets designed for display on the outside of the doors of patient rooms to alert staff to patients not to receive hot beverages (a magnet with the picture of a coffee cup with a universal "no" sign over it). Both staff members stated "no" (the two options had not been implemented). The risk management staff member stated that education was being conducted for staff and that the education portion of the plan had not been completed. When asked what was currently being implemented to assure patients were protected from burns from hot liquids it was stated that temperatures were being checked periodically. When asked if temperatures were being checked as planned by the "NO BURN" committee, it could not be confirmed that the temperatures had been checked as scheduled. When asked if nursing staff had the ability to check temperatures prior to delivery of coffee or hot water from the floor nutrition areas to a patient, it was revealed staff on the floor did not have the capability to check liquid temperatures. When asked if there were patients identified as being at risk for injury included those without the dexterity or strength to prepare their own tea or hot chocolate, patients with limited range of motion, those of advanced age, limited range of motion, and/or cognitive decline currently hospitalized within the facility the response was "yes." When asked if the prevention of patient burns could be assured due to lack of implementation of initiatives of the "NO BURN" committee recommendations the response was that, "due to education not being completed and magnets not being put into use that the potential for patient burns still existed."

Based on observation, interview and record review, the facility failed to:
- provide a safe environment by neglecting to monitor hot beverage temperatures, resulting in 4 patients sustaining burn injuries (patients #10, #13, #14, #15) since January 19, 2014. (A-0144)
-inform 1 of 1 patient's representative (patient #13's) of the extent of burn injuries and follow-up care needed post-discharge, resulting in increased risk of all patient representatives being deprived of information needed to participate in treatment planning. (A-0131)

Based on interview and record review, the facility failed to provide the representative of 1 of 1 patients who sustained a burn injury (#13) with information on the patient's wound assessments during hospitalization and a Plastic Surgery consultation with post-discharge treatment recommendations, resulting in increased risk of poor health outcomes for all patients with representatives. Findings include:

On 4/3/14 from 0900 to 1600, a review of Patient #13's clinical record revealed a signed and executed Durable Power of Attorney for Health Care document. At admission, the patient's Power of Attorney for Health Care signed consent forms for treatment of patient #13. Patient #13 record revealed a diagnosis of dementia and contained daily documentation of impaired mental status during hospitalization.

No documentation of patient #13's Power of Attorney for Heath Care being notified of the patient's burn on 1/20/14 was found. Documentation of wound updates being provided to the patient's representative during hospitalization were not found. A January 29, 2014 Plastic Surgery Consult by Dr. P. states: "I would like to re-evaluate the patient in 1 week (post-discharge)." No documentation stating that the patient's Health Care Power of Attorney was informed of the severity of the patient's burns or the need for an appointment with Plastic Surgery post-discharge was found. The "Patient Instructions" portion of the Discharge Summary provided for review was dated 1/31/14. (The patient was discharged 1/30/14.) No appointments for follow-up with a Plastic Surgeon were listed under "Your Appointments." These findings were verified by staff D on April 3, 2014 at approximately 1600.

Based on observation, record review and interview the facility failed to to protect 4 of 4 patients (#13, #10, #14 and #15) from burns from hot liquid beverages resulting in four patients receiving burns. Findings include:
Observations:
On April 3, 2014 from 0950-1030 observations were made in three unit kitchens, on floors 5, 6 and 7, where hot beverages for patient use are dispensed. A poster, titled "N.O.B.U.R.N." was observed posted near hot beverage dispensers. The poster states: "A safe temperature for hot beverages in the hospital is 130-140 degrees F." On April 3, 2014 at approximately 1000 the Director of Inpatient Nursing stated that this is the hospital's policy. Thermometers for checking hot water temperatures were not available on floors 5, 6 and 7.

On April 3, 2014 from 0950-1030 hot beverage temperatures on three unit kitchens, with coffee makers and hot water spigots (Insta-Hot brand) for patient beverages were tested by the Supervisor of Operations. The following temperatures of hot liquids available for patient beverages on floors 7, 5 and 6 were observed:
--At 0950 on the 7th Floor, coffee was dispensed at 161.2 F. (degrees Fahrenheit) and hot water was dispensed from the Insta-Hot dispenser at 153.5 F.167.9 F.
--At 1000 on the 5th Floor, coffee was dispensed at 167.9 degrees F. and hot water was dispensed from Insta-Hot at 144.1 F.
-- At 1015 on the 6th Floor, coffee was dispensed at 176.5 F and hot water was dispensed from Insta-Hot at 128.5 F.
All observations (above) were verified by the Director or Inpatient Nursing and Supervisor of Operations on April 3, 2014 from 0950-1030.

Record Review:
On 4/4/14 between 0900 and 1600 the medical record for Patient #13 was reviewed and revealed the following: the patient was scalded by a carafe of a hot beverage left at her bedside on January 20, 2014. On January 20 at 0730 and 1600 patient #13's nurse, staff Q, documented that the patient was "A & O x 1-2" (alert and oriented in 1-2 spheres) and "confused." Patient #13 sustained burns on the right lower back and right buttock, according to a physician's note by Dr. R., on 1/20/14 at 1820. Dr. R. diagnosed 2nd degree burns and ordered that Silvadene Cream be applied to the burns twice daily. Dr. R. stated that patient #13 was "A & O x 1." A January 20, 2014 (post-incident) "Nursing Note" by staff Q documented: "burns to RUE (right upper extremity) and R (right) thigh." On 1/29/14 a Plastic Surgery Consultant by staff P stated, "The patient has a burn injury involving the right back, buttock and right upper thigh, lateral aspect, consistent with having spilled a hot liquid with some pooling in that dependent area." Dr. P described the wound as: "possibly full thickness in areas."

Interviews:
On April 3, 2014 at 0930 the Supervisor of Clinical Nutrition stated: "hot water temperatures leaving the kitchen are not being monitored on a regular basis." On April 3 at approximately 1140 the Supervisor of Operations (staff I) stated that the most recent monitoring did not show that patient hot beverage temperatures within range (per policy, 130-140 degrees) on all units and that beverage temperatures were not being monitored and documented on a routine basis.


29955

On April 3, 2014 at approximately 1000 a review of facility's complaint and grievance log for the past six months from October 1, 2013 to March 31, 2014 occurred. The focus of the review was occurrences in relation to patient rights and nursing services. A review of the facility's adverse occurrence and sentinel event log was conducted on April 2, 2014 at approximately 1340. On April 3, 2014 at approximately 1000 during a review of the adverse event and sentinel event log, four events of patient burns were identified and had occurred as follows: January 19, 2014, January 20, 2014, January 24, 2014, and February 2, 2014. The complainant's burn was identified through the review of the events. Patients' who sustained burns medical charts were requested for review. During review of the four charts it was found that all patient burns had occurred as a result of hot beverages being left at the bedside for patient consumption. Patient #10 sustained burns on January 19, 2014 to the abdomen from a carafe of hot water left at the bedside. The patient (#10) was seen by the house physician on January 19, 2014 and treatment for the burned area was ordered. Patient #13 was burned on January 20, 2014 from a carafe of hot water being left at the bedside. Patient #13 sustained burns on her left hand, right thigh, back and buttock. The house physician saw (patient #13) on January 20, 2014 at 1848. Treatment was ordered and a consult for a plastic surgeon was ordered. According to the documentation the patient (#13) was released to an extended care facility and her wounds became infected requiring hospitalization. The patient (#13) required debridement and skin graft surgery. Patient #14 was burned on January 24, 2014 from a cup of hot water being left at the patient ' s bedside. The patient (#14) was seen by the house physician on January 24, 2014. The patient sustained burns to the left thigh and scrotum. A consult for the wound care nurse was ordered on January 24, 2014 but the patient was not seen by the wound care nurse before discharge as the patient was discharged prior to the wound care nurse being able to see the patient. On February 2, 2014 patient #15 sustained a burn from a hot carafe of water being left at the patient ' s bedside. The patient sustained burns to her left outer leg. The patient (#15) was seen by the house physician on February 2, 2014. The patient was seen by the wound care nurse for treatment on February 3, 2014. The patient (#15) subsequently transferred to the rehabilitation unit where she was followed and cared for by the wound care nurse. Patient #15 was scheduled to see a plastic surgeon three weeks from March 12, 2014.

On April 2, 2014 at approximately 1545 a review of the root cause analysis of the patient burn events occurred. On January 30, 2014 a committee was established to address the identified problem of patients receiving burns as a result of hot liquids being served for consumption. The committee established criteria of assessing patients at risk for potential harm from hot liquids being served at the bedside. Patients identified as being at risk for injury included those without the dexterity or strength to prepare their own tea or hot chocolate, patients with limited range of motion, those of advanced age, limited range of motion, and/or cognitive decline. All "Instahot" (levers controlling dispensing of hot water) levers were removed from coffee dispensers on the units and a schedule of checking the temperatures was developed. Education for all nursing staff and dietary staff was to be conducted. During a review of temperature check logs it was discovered temperature checks had not been conducted or documented on patient beverages as planned. During review of the educational material the facility was unable to provide evidence regarding which staff attended or completed the training in order to determine which staff members had received education.

On April 3, 2014 at approximately 1420 an interview was conducted with staff B and staff C. The question was asked if initiatives to prevent burns stated in the "NO BURN" committee plans had been implemented specifically, the use of "no hot beverages" option for dietary orders and the use of magnets designed for display on the outside of the doors of patient rooms to alert staff to patients not to receive hot beverages (a magnet with the picture of a coffee cup with a universal "no" sign over it). Both staff members stated "no" (the two options had not been implemented). The risk management staff member stated that education was being conducted for staff and that the education portion of the plan had not been completed. When asked what was currently being implemented to assure patients were protected from burns from hot liquids it was stated that temperatures were being checked periodically. When asked if temperatures were being checked as planned by the "NO BURN" committee, it could not be confirmed that the temperatures had been checked as scheduled. When asked if nursing staff had the ability to check temperatures prior to delivery of coffee or hot water from the floor nutrition areas to a patient, it was revealed staff on the floor did not have the capability to check liquid temperatures. When asked if there were patients identified as being at risk for injury included those without the dexterity or strength to prepare their own tea or hot chocolate, patients with limited range of motion, those of advanced age, limited range of motion, and/or cognitive decline currently hospitalized within the facility the response was "yes." When asked if the prevention of patient burns could be assured due to lack of implementation of initiatives of the "NO BURN" committee recommendations the response was that, "due to education not being completed and magnets not being put into use that the potential for patient burns still existed."