Failure to Check Hot Liquid Temperature Results in Resident Burn
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure the temperature of a cup of soup was checked prior to serving it to a resident with significant risk factors. The resident had a history of polyneuropathy, rheumatoid arthritis, contractures, and functional limitations in the upper extremities, resulting in reduced sensation and mobility. The care plan identified the resident as being at risk for hot liquid injury and specified that staff should assist with hot liquids and provide a cup with a lid. Despite these precautions, a Certified Nursing Assistant (CNA) heated the resident's instant cup of noodle soup in the microwave and did not take the temperature before serving it. The resident, who was cognitively intact but had limited sensation in his fingers, tested the soup's temperature by dipping his left pointer finger into the bowl. Due to his neuropathy, he was unable to feel the heat and sustained a second-degree burn, resulting in blistering and removal of the fingernail. The injury was observed and documented by nursing and therapy staff, and the wound required debridement. Interviews with facility staff, including the CNA, Licensed Vocational Nurse (LVN), Registered Dietician (RD), and Administrator, confirmed that the facility's policy required hot liquid temperatures to be checked before serving, but this was not done. Additionally, CNAs had not received training on taking food temperatures prior to serving residents. Facility policies reviewed emphasized the importance of monitoring hot liquid temperatures to prevent burns, particularly for residents with impaired sensation or mobility.