Resident Burned by Unchecked Hot Beverage Temperature
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction and unspecified dementia, who required set up or clean up assistance with eating or drinking, was served hot tea without the temperature being checked. The Certified Nurse Assistant (CNA) poured hot water from a coffee pot in the hall's pantry and gave it to the resident, then left the room to assist another resident. After approximately eight minutes, the CNA returned and found that the hot tea had spilled on the resident, resulting in burns. The nurse assessed the resident and noted what appeared to be a third-degree burn on the right hip area, and the resident was subsequently sent to the emergency room and then transferred to a burn unit, where a second-degree burn was confirmed and a skin graft was performed. Prior to this incident, the facility did not have a policy regarding the serving temperature of hot beverages, nor were there postings or thermometers available in the pantries for staff to check beverage temperatures. Staff interviews confirmed that it was not standard practice to check the temperature of hot beverages before serving them to residents. The CNA involved in the incident reported that she could not find a thermometer and relied on the absence of steam to judge the temperature, which proved inadequate. Other staff corroborated that temperature checks were not routinely performed before the incident. Observations and record reviews revealed that the facility's temperature logs for hot beverages showed a wide range of serving temperatures, some of which exceeded safe limits. There were also gaps in documentation for certain dates. Additionally, the Activities Director reported serving coffee during activities without checking temperatures. The lack of a clear policy, absence of temperature monitoring, and failure to provide adequate supervision when serving hot beverages directly contributed to the resident sustaining significant burns.