Failure to Check Hot Water Temperature Results in Resident Burn
Penalty
Summary
The facility failed to ensure the hot water temperature was checked before serving it to a resident, resulting in actual harm. The incident involved a resident who was cognitively intact and independent with eating. After dinner, the resident was enjoying a cup of hot tea when it spilled onto their lap, causing a blister on the left upper and outer thigh. The facility's policy required hot beverages to be served at temperatures between 140 and 155 degrees Fahrenheit, but the temperature of the hot water provided to the resident was not checked by the dietary aide. The dietary aide, who served the hot beverage, admitted to not measuring the temperature of the hot water before serving it to the resident. The facility's protocol required the hot beverage temperature to be measured before being placed on the resident's tray, but this step was not followed. The dietary manager confirmed that the hot water provided to the resident had not been checked to verify if it was at a safe serving temperature. The incident was further compounded by the fact that the resident's meal was delivered directly to their room, and when the resident requested additional items like sugar or a tea bag, the dietary aide brought another cup of hot water without checking its temperature. This oversight led to the resident sustaining burns, with blisters and redness on the thigh, and required medical attention, including the application of Silvadene cream as prescribed by a physician.
Plan Of Correction
Resident R1 was immediately assessed by the charge nurse with first aide provided. Attending Physician was made aware. A new order was obtained for treatment to the area. A wound consultation was also ordered. The resident was noted as their own responsible party who was made aware of the treatment and consult orders. Resident R1 was discharged from the facility on 1.8.2025. No other residents were affected. Current residents have the potential to be affected. The dietary department will not serve hot liquids to residents that are outside the parameters of our policy regarding safe holding and serving temperatures for hot beverages. Hot beverage air pots without temperature indicators were removed from the units, and a Keurig coffee maker was removed from the unit. The Dietary Manager educated the dietary team members on the importance of completing and documenting temperatures of hot beverages prior to serving during each meal to ensure serving temperatures are within acceptable range. Hot temperature logs will be monitored by the Dietary Manager or designee daily for one month, followed by weekly for two months to ensure compliance. Non-compliance will be reported to the Administrator for follow-up. Findings will be submitted to the QAPI committee monthly, for three months for review. The committee will determine if further audits and/or actions are required. The Administrator is responsible for ensuring implementation of and ongoing compliance with this plan of correction and addressing and resolving variances as they may occur.