Routinely serving hot drinks without protective lids, thereby increasing the risk of severely burning residents, always results in the submission of a false claim.
Compliance Perspective – Burned Resident
Policies/Procedures: The Compliance and Ethics Officer with the Food Services Director will review policies and procedures involving the serving of hot beverages with protective lids.
Training: The Compliance and Ethics Officer with the Food Services Director will ensure that staff are trained to respond in a timely manner to concerns about hot beverages served to residents without protective lids, as well as safe temperatures for serving hot liquids.
Audit: The Compliance and Ethics Officer with the Food Services Director should personally audit the use of protective lids on all hot beverages served to residents.
A Certified Nursing Assistant (CNA) in a hurry to get hungry, complaining residents their meals after kitchen staff were delayed in delivering the residents’ dinner, served a cup of hot chocolate without a protective lid to a resident. The resident who was seated in her wheelchair bumped the cup, and it spilled onto her lap and pooled beneath her thigh. The CNA and a nurse cleaned up the spill, rolled up the resident’s pant leg to check her skin and applied a cool, moist towel to the area that was red from the hot chocolate spill.
A Licensed Nurse Practitioner suggested the resident return to her room, but she declined. The resident stayed for 20 minutes, seated in her wheelchair, and finished her dinner. The 2nd degree burn resulted in blisters and breaks in the resident’s skin that were slow to heal. In retrospect, the resident’s husband warned the nursing staff during the admission process that the resident tended to not voice her feelings of pain and would often deny pain when asked.
After the incident, inspectors learned from the husband that the resident remained in her wheelchair for a quite a while. She was not moved out of the chair until bedtime.
The state determined that in addition to the woman who was burned, 100 other residents were put at risk for the same injury because staff failed to provide cups with lids for their hot drinks.
