Failure to Ensure Hot Liquid Safety Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident with a history of cerebral vascular accident resulting in left-side hemiplegia. The resident, who was alert, oriented, and able to communicate preferences, requested a cup of coffee using his own K-Cup and specified that he did not want a lid on the cup. The coffee was prepared by a nurse aide using a Keurig machine and delivered to the resident's bedside table without the temperature being checked, as was the usual practice at the time. Shortly after receiving the coffee, the resident attempted to drink from the open cup, which slipped from his hand and spilled onto his left thigh. The incident resulted in the formation of blisters and redness on the resident's thigh, as documented in the nursing note. The resident reported mild pain, and the affected area was treated by staff. There was no evidence that the temperature of the coffee was measured prior to serving, and the facility's hot liquid safety policy was not applied to nursing staff, only to kitchen staff. Interviews with staff confirmed that the temperature of hot liquids from the Keurig was not routinely checked before serving to residents. The nurse aide involved in the incident stated that she followed the resident's request for no lid and did not measure the temperature of the coffee. The DON confirmed the lack of documentation regarding temperature checks and clarified that the policy was not extended to nursing staff at the time of the incident.