Failure to Supervise and Ensure Safe Hot Beverage Service Results in Resident Burn
Penalty
Summary
The facility failed to ensure adequate supervision and safe practices when serving hot beverages to a severely cognitively impaired resident who required assistance with activities of daily living, including setup of food and drink. The resident, who also had hemiplegia, hemiparesis, and aphasia, was given a cup of hot cocoa that had not been checked for temperature, was not provided with the required lid, and was left unsupervised in a hallway. The resident subsequently spilled the hot beverage on their lap, resulting in third-degree burns to their thighs and a blister between the right thigh and buttocks. Interviews and record reviews revealed that staff did not consistently check or document the temperatures of hot liquids before serving, as required by facility policy. The dietary manager confirmed that temperature checks were supposed to be performed and documented, but there was no record of such checks for the evening snack cart. Additionally, the specific mug with a heavy lid, intended to prevent spills for this resident, was not used at the time of the incident, and the care plan did not document this requirement prior to the incident. Temperature logs showed that hot liquids were often above the facility's maximum allowable temperature.