Resident Burned by Hot Beverage Due to Lack of Staff Training and Unsafe Temperatures
Penalty
Summary
A deficiency occurred when a resident with chronic kidney disease, dependence on renal dialysis, and diabetes, who was cognitively intact, sustained a second-degree burn after spilling hot chocolate on their thigh. The hot chocolate was prepared by a nursing assistant using a Keurig coffee maker in the facility's kitchenette. The incident resulted in a burn measuring 7 by 12 centimeters and 0.1 centimeters deep, with 30% scabbing and involvement of both the dermis and epithelial layers of the skin. The resident reported significant pain from the burn. Investigation revealed that the water dispensed from the Keurig machine reached a temperature of 180.3°F, which exceeds the recommended safe serving range of 130 to 160°F for hot beverages. Staff interviews indicated that nursing assistants had not received education on safe temperatures for reheating or serving food and beverages, and the staff educator confirmed that such training was not provided to any staff members. The administrator acknowledged awareness of the incident and the lack of staff education regarding the risks associated with hot liquids.