Failure to Monitor Hot Beverage Temperatures and Supervise Leads to Resident Burn
Penalty
Summary
The facility failed to ensure that hot beverages were monitored and served at a safe temperature on the nursing units, resulting in residents being placed at risk for burn injuries. Observations and interviews revealed that staff did not routinely test the temperature of hot beverages before serving them to residents, and coffee was served at temperatures as high as 181 degrees Fahrenheit. The facility's policy allowed hot beverages to be served at temperatures above 155 degrees Fahrenheit, which is contrary to safety recommendations from the American Burn Association, and there was no evidence that beverages were retested at the point of service before being given to residents. A resident with significant medical conditions, including Parkinson's disease, Lewy body dementia, apraxia, and cognitive impairment, required assistance with meals and supervision during self-feeding. Despite these needs, the resident was observed unsupervised in the dining room on multiple occasions, drinking coffee without a lid. The resident sustained a burn injury to the abdomen after spilling hot coffee, which was measured at 15 cm by 2 cm. The incident was discovered when the resident was heard screaming, and staff noted the spill and resulting burn. Further interviews with dietary and nursing staff confirmed that they did not typically test the temperature of coffee before serving it to residents. Residents also reported that the coffee was too hot to drink and needed to sit before it could be consumed. The lack of temperature monitoring, failure to provide required supervision, and absence of adaptive equipment contributed to the incident, resulting in actual harm to a resident and the identification of an Immediate Jeopardy situation.