Resident Burned by Unchecked Hot Soup Due to Staff Failure to Follow Reheating Policy
Penalty
Summary
A severely cognitively impaired resident with a history of dementia, cognitive communication deficit, and peripheral vascular disease sustained significant burn injuries after being served reheated soup by a CNA who failed to check the soup's temperature before serving. The resident required setup or clean-up assistance when eating and had care plans in place for both ADL self-care deficits and risk for skin injury. During dinner, the resident pulled the bowl, causing the hot soup to spill onto their lap, resulting in second- and third-degree burns to the right inner and anterior thigh, with an open area and extensive redness documented. The facility's report and subsequent documentation confirmed that the CNA did not use a thermometer to ensure the soup was at a safe temperature prior to serving, despite the presence of both a sign and a thermometer at the microwave. The facility's policy required staff to use a thermometer to check that soups and hot cereals were reheated to 165°F and cooled to no more than 150°F before serving. The CNA admitted to forgetting to check the temperature, and the incident was reported to the DON and other relevant staff. Review of staff training records revealed that the CNA involved had not received recent or up-to-date training on microwave use and reheating procedures prior to the incident. Another CNA's file also lacked evidence of required training before the incident date. The facility's policies mandated that competencies for such procedures be completed at hire and annually, but documentation did not support that this was consistently done for the staff involved.