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Based on interview and record review, the facility failed to supervise intake and provide thickened liquids to P-1 resulting in injury; and failed to document corrective actions/education provided to staff regarding the level of assistance P-1 needed with meals, following diet orders, and implementing speech language pathology recommendations, resulting in the potential of reoccurrence and the potential of a missed opportunity to improve patient safety. Findings include:

See tag A-0144: Failure to provide care in a safe setting.

Based on interview and record review, the facility failed to supervise intake and provide thickened liquids to P-1 resulting in injury; and failed to document corrective actions/education provided to staff regarding the level of assistance P-1 needed with meals, following diet orders, and implementing speech language pathology recommendations, resulting in the potential of reoccurrence and the potential of a missed opportunity to improve patient safety. Findings include:

P-1 was a 92-year-old male was admitted to facility on 12/6/24 with confusion and a history of dementia, dysphagia (difficulty swallowing), and limited mobility. A diet order was placed on 12/6/25 at 1520 for a dental soft, dysphagia diet with nectar thick liquids. Occupational Therapy (OT) notes of 12/6/2024 revealed: P-1 at time of the initial OT assessment could not follow instructions, was orientated to person, impulsive, and needed maximum assist with upper body skills. Speech Language Pathologist (SLP) consult of 12/8/24 at 1204, recommended to continue dysphagia, dental soft diet with nectar thick liquids, 1:1 feed assist, sit fully upright with all oral intake, small bites, sips at a slow rate. Notes also indicate these recommendations were discussed with nurse.

Review of incident report revealed on 12/9/24 between 0800 and 0900, hot coffee, not thickened to nectar thick consistency, was given to P-1 by a nursing assistant, and P-1 was left unattended during oral intake. P-1 sustained second degree burns, due to spilling coffee on his left abdomen and upper hip.

On 3/25/25 at 1323 an interview with Nursing Manager Staff R on 3/25/25 at 1323 revealed that an investigation was conducted, and it was determined that that coffee was served to P-1 as a "thin liquid", by the nursing assistant assigned to P-1 (per P-1's request for a cup of coffee). Coffee was served in a styrofoam cup with a lid, and it was confirmed a microwave was not used to heat up coffee.

Record review revealed corrective actions/education to nursing staff post investigation was not documented nor was it included in the risk investigation report.

On 3/26/25, review of policy titled, "Patient Safety and Precautions" dated 7/9/24 revealed, "Precautions are bundles of assessment and prevention steps for high-risk clinical conditions ...Each individual patient's Precautions are clearly identified in the Electronic Health Record (EHR)... which displays the specific Precaution title in the patient header for easy identification ... by all care team members. Some precautions have routine, clearly outlined steps, others require individualization ...Indications to Initiate Aspiration Precautions ...High risk patients include: any degenerative neurological disease (...dementia, Alzheimer's, etc.), stroke... history of dysphagia/on dysphagia diet prior to admission .... Aspiration precautions should be followed on all high-risk patients during meals regardless of swallow screen outcome ... Interventions ... Refer to patient specific instructions in diet order comments provided by Speech Language Pathology evaluation."