F0689

G

Burn Injury from Overheated Hot Liquid and Inadequate Temperature Monitoring

Ellis, Kansas Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent a hot liquid burn to a resident by not evaluating and monitoring the temperature of liquids dispensed from a hot water/coffee machine and instead relying on a temperature regulator that was not functioning. The resident involved had paraplegia with motor and sensory impairment of both upper and lower extremities, gastroparesis, epilepsy, and convulsions, and required total assistance with ADL self-care. The resident’s MDS documented intact cognition but impairment of bilateral upper and lower extremities, with a need for set-up or clean-up assistance with eating and dependence on staff for all other ADLs. The care plan identified an impaired ability to manage hot beverages and soups related to paraplegia, directed staff to offer foods at a liquid state at room temperature, and specified that hot beverages should be served in a mug with a lid, with reminders to be cautious with hot beverages and soups.

On the day of the incident, a licensed nurse poured hot chicken broth for the resident in the dining room, placed it in a cup with a lid, and then placed the cup on the resident’s bedside table while the resident was in bed with the head of the bed elevated. A few minutes later, housekeeping staff heard the resident calling for help and found that the resident had spilled the hot chicken broth on himself. The liquid had escaped through the straw opening in the lid. The resident later explained that the nurse had set the broth on the middle edge of the bedside table closest to his body, and when he reached over the broth to get something in the middle of the table, he knocked the cup off to the left side. He stated he could not grab the cup and that it was leaking hot broth, and he attempted unsuccessfully to sop up the liquid with a napkin.

Following the incident, assessments documented reddened areas and later blistering on the resident’s left elbow and left lateral abdomen consistent with a hot liquid burn. Initial measurements showed large reddened areas on the left elbow and abdomen, and subsequent documentation noted open blisters and pain with dressing changes, leading to the use of Silvadene cream and sterile dressings until the wound healed. After the burn occurred, administrative nursing staff manually checked the temperature of the hot water from the dispenser and found it measured 159°F immediately after dispensing and 154°F within a couple of minutes. Administrative nursing staff acknowledged that the facility did not regularly check the temperatures from the water/coffee machine because they relied on a built-in temperature regulator that was supposed to keep the temperature below 150°F, and they did not realize the regulator was not working until after this incident. The facility’s own hot liquids policy called for consideration of serving self-service hot liquids at or below 150°F and for evaluating residents with medical conditions that put them at risk for spills, allowing liquids to cool, and adding care plan interventions from the Hot Liquid Safety focus, underscoring that the failure to monitor and control the machine’s output temperature and to ensure safe serving conditions led to the resident’s burn.

The resident consistently reported that the burn occurred when he accidentally knocked the hot beverage while reaching across his bedside table, and he initially stated he did not feel the event was traumatic, though he did report pain associated with the burn and dressing changes. Observations after the incident showed a dark pink area on the left outer elbow where the burn had been, in contrast to the resident’s pale surrounding skin. The documentation and interviews collectively show that the resident’s known physical impairments, dependence on staff, and identified risk related to hot liquids were present at the time of the event, and that the hot liquid was dispensed at a temperature above the facility’s policy threshold due to the unmonitored failure of the machine’s temperature regulator. These actions and inactions resulted in an actual burn injury to the resident.