Failure to Maintain Safe Water Temperatures Results in Resident Burn
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by not ensuring that water temperatures provided to residents for consumption were within a safe range. Staff provided a cup of hot water to a resident, who then delivered it to another resident for the purpose of making instant coffee in their room. The water, obtained from a new coffee system, was measured at temperatures between 179 and 189 degrees Fahrenheit, significantly higher than the recommended safe serving temperature. There was no system in place to monitor or regulate the temperature of water dispensed from the new coffee system, and staff were unaware of the actual temperature being provided to residents. A resident with significant medical conditions, including left-sided hemiplegia, polyneuropathy, stroke, diabetes, and decreased pain sensation due to medication, received the hot water and subsequently spilled it on themselves. The incident resulted in a second-degree burn extending from the right flank to the right mid-thigh. The burn was described as a large, irregular area with the top layer of skin missing, and the resident did not report pain due to their medical condition and medication regimen. The event was not immediately or thoroughly documented in the resident's care plan or incident reports, and there was a lack of timely and complete assessment and documentation of the injury, including measurements and detailed descriptions. Interviews with staff revealed that the dietary aide who provided the hot water did not check the temperature before giving it to the resident and was unaware that the water was intended for another resident. The staff member allowed the water to cool for approximately 15 minutes but did not verify its safety. The new coffee system had only recently been installed, and staff had not been trained or made aware of the increased water temperature. There was confusion among staff regarding the facility's policy on acceptable serving temperatures, and no maximum temperature was specified in the policy. The lack of clear procedures and oversight contributed to the incident and the resulting injury.