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F0689
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Failure to Implement Hot Liquid Safety Interventions Results in Resident Burn

Belle Fourche, South Dakota Survey Completed on 09-29-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff failed to implement required safety interventions for a resident identified as being at risk for burns from hot liquids. The resident's care plan and Hot Liquid Safety Evaluation specified the need for a cup with a lid and a clothing or lap protector when consuming hot beverages. Despite these documented interventions, the resident was served hot coffee in her personal Thermos cup without verification of the coffee's temperature, and she was not provided with a clothing protector at the time. The coffee, obtained from the employee breakroom where temperatures were not monitored, was too hot, resulting in the resident expelling it onto her chest and sustaining small blisters. Further review and interviews revealed that the kitchen did not maintain a list of residents requiring specific accommodations for hot beverages, and there were no lidded mugs available for general resident use. The resident sometimes used unlidded mugs from the kitchen, contrary to her care plan. Staff, including the CNA and kitchen staff, were unaware of the temperature differences between coffee sources and did not consistently follow the interventions outlined in the resident's care plan to mitigate the risk of burns from hot liquids.

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