Resident Burned by Unchecked Hot Beverage Temperature
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis, following a cerebral infarction, suffered a burn injury after spilling reheated coffee on his lap. The incident resulted in a blistered area on the resident's upper right thigh, with medical records confirming a partial thickness burn. The resident did not report pain at the time, but the injury required wound care and follow-up by medical staff. The facility's policy required staff to reheat resident food and beverages to a temperature not exceeding 140 degrees Fahrenheit and to verify this with a thermometer before serving. However, staff involved in the incident were unaware of this policy at the time. The coffee was reheated by a staff member who did not check the temperature, and the beverage was subsequently handed to the resident without verifying its safety. The CNA who assisted the resident was also unaware of the temperature-check requirement and only learned of the burn after the resident reported it the following day. Interviews with staff and review of facility procedures revealed that the policy regarding reheating and temperature checks was not communicated or enforced prior to the incident. Staff members, including the CNA and the individual who reheated the coffee, confirmed they had not received education on the policy before the event. The lack of staff awareness and failure to use the required equipment to ensure safe serving temperatures directly contributed to the resident's burn injury.