Failure to Serve Food at Safe Temperature Results in Resident Injury
Penalty
Summary
A deficiency occurred when a staff member failed to serve food at a safe and appetizing temperature, as required by facility policy. Specifically, a cook served tomato soup at a temperature of 171 degrees Fahrenheit, which exceeded the facility's acceptable serving range of 140 to 165 degrees Fahrenheit for hot entrees. The soup had been cooked to 181 degrees and was plated at 171 degrees, without being cooled to the appropriate serving temperature prior to delivery to residents. As a result, a resident who was eating in his room accidentally spilled the hot soup on his chest and left arm. The resident experienced mild skin redness and stinging, though no blisters or significant pain were reported. The redness resolved within a short period, and the resident's skin remained intact. The incident occurred while the facility was serving meals in resident rooms due to a flu outbreak, which increased the time between plating and delivery, prompting staff to keep food at higher temperatures on the steam table. The resident had a history of hot liquid safety assessments, with interventions such as lidded cups and staff assistance being implemented and adjusted over time based on periodic reassessments. At the time of the incident, the resident was considered not at risk for hot liquid injuries, and the intervention for a lidded cup had been removed. The soup spill led to a reassessment and the reintroduction of safety interventions for hot liquids.