State Findings:
Based on observation, record review, staff and resident interviews, facility staff failed to provide supervision and assistance for one of 11 residents reviewed for accidents. Actual harm occurred when R#2 sustained [CONDITION(S)] to his right thigh after spilling coffee on himself when he was allowed to self-transport hot coffee via wheelchair without staff assistance.
Interview on 5/20/2021 at 1:02 p.m. with DA LL confirmed that she could not recall if she was the person who gave the coffee to R#2 on 3/24/2021. However, she had given the resident coffee before without setting the coffee on the table for him. DA LL reported that she had observed R#2 transferring coffee in his wheelchair while propelling out of the kitchen area. Previously she would hand resident the coffee mug through the kitchen door and R#2 would transport the coffee in his wheelchair. DA LL stated that she did not consider R#2 transferring the coffee in his wheelchair as a safety issue until after he sustained a burn from the hot coffee spill.
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Personal Note from NHA-Advocates
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