LAWRENCEVILLE, GA – LIFE CARE CENTER OF GWINNETT

Based on observation, interviews, record review, review of the facility policies titled Reducing the Risk [MEDICAL CONDITION] Residents from Hot Beverages and Feeding a Resident, the facility failed to provide adequate supervision when offering hot beverages for three residents (R) (#85, #99, and #33) of 38 sampled residents. The three residents [MEDICAL CONDITION] their body which resulted in actual harm.

During an interview on 4/24/19 at 3:33 p.m., the Administrator stated the burn incident occurred around 5:30 p.m. on 4/5/19. He completed an investigation which revealed Certified Nursing Assistant (CNA) MM served hot coffee to R#85. R#85 was lying in bed and the coffee spilled, burning his leg. After completion of the investigation, CNA MM was terminated due to failure to follow facility policy on serving hot beverages. Administrator stated facility policy is that temperature checks are completed on all hot liquids leaving the kitchen. He further stated that the coffee company came to the facility to lower the coffee machine temperatures to less than 165 degrees.

An interview on 4/24/19 at 3:47 p.m. with Assistant Director of Nursing (ADON) revealed R#85 requested a cup of coffee. CNA MM went to the kitchen, requested a cup of coffee and was told by dietary staff to serve herself. CNA MM obtained the coffee and provided it to the resident. ADON further stated that after the incident, all coffee pots were removed from the pantries and thermoses are now in their place.

An interview with Wound Care Physician on 4/26/19 at 3:28 p.m. revealed he was unable to assign a degree of burn to R#85’s wound due to the amount of necrotic tissue present and the wound has some full to partial thickness involvement. The wound is healing as expected and requires some debridement. The wound is superficial in nature. He further stated that if the wound was a third degree burn, the resident would have been sent to a wound clinic.