Failure to Ensure Safe Serving Temperature of Hot Beverages Resulting in Resident Burns
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) served a hot beverage to a resident without checking the temperature to ensure it was within a safe serving range. The resident, who had a history of metabolic encephalopathy and multiple strokes resulting in right-sided hemiplegia, required supervision and set-up assistance with eating. Despite these needs, the CNA heated water in a microwave, prepared tea, and served it to the resident without verifying the temperature, contrary to facility policy. The incident resulted in the resident spilling the hot beverage on herself, causing significant burn injuries to her right breast and shoulder. Documentation and interviews confirmed that the resident experienced severe pain and required medical intervention, including an emergency room visit and follow-up wound care for second and third degree burns. The resident's care plan indicated a need for assistance with eating, and staff interviews revealed that the CNA was unaware of the requirement to check beverage temperatures before serving, while another CNA confirmed that such checks were part of their training and policy. Facility policies reviewed specified that hot beverages must be served at or below 155°F and that temperatures should be measured with a calibrated thermometer prior to service. The Director of Nursing confirmed that the CNA did not follow this policy, leading to the resident's injury. The resident recalled not being warned about the hot beverage and did not remember if the spill was caused by staff or occurred after she awoke from a brief sleep.