Failure to Educate Staff on Safe Food Heating Results in Resident Burn
Penalty
Summary
The facility failed to ensure that direct care staff were educated on the safe process for heating and reheating food, as required by facility policy. The policy specified that food and beverages must be heated, stirred, temperature-checked, stirred again, and re-checked before being served to residents, with temperatures maintained between 140°F and 165°F to minimize the risk of burns. However, a licensed nurse who had not received this education prepared instant ramen soup for a resident and did not check the temperature before serving it. The resident involved had diagnoses of diabetes and peripheral vascular disease, was cognitively intact, and required set-up assistance with feeding. After the soup was served, the resident spilled it on their chest, resulting in a second-degree burn. Observations and clinical documentation confirmed the presence of a significant burn area on the resident's chest and abdomen, and the resident reported pain following the incident. Progress notes and wound care consults documented the extent and treatment of the burn. Interviews and facility documentation revealed that the nurse did not follow the required procedure for checking food temperature, and there was no evidence of temperature documentation for the soup. The Nursing Home Administrator confirmed that the staff member had not been trained on the safe food heating policy, and further acknowledged that all direct care staff, including nurses and nursing assistants, had not received this education. This lack of staff education and failure to follow policy led to an Immediate Jeopardy situation when the resident sustained a burn from overheated food.
Removal Plan
- Education was provided to the staff
- A whole house audit was conducted to check all microwaves in the facility had thermometers attached to it
- All residents were assessed to ensure no other residents received a burn from re-heated food items
- Process signage for re-heating food in the microwave were attached to the microwaves
- House-wide education developed and implemented for all facility staff on re-heating process, education was implemented and presented during the new hire and agency orientation
- Dietary performed audits to ensure thermometers are present and functioning on all microwaves in resident areas
- Audits were completed and ongoing
- The outcome of audits will be reviewed at the QA meeting