Failure to Safely Serve Hot Liquids Resulting in Burn Injury
Penalty
Summary
The deficiency involves the facility’s failure to safely serve hot liquids, resulting in a second-degree burn blister for one resident. The resident had a history of muscle weakness and hemiplegia/hemiparesis following a cerebral infarction affecting the left non-dominant side, required staff assistance with bed mobility and transfers, and had intact cognition with a BIMS score of 14/15. On the day of the incident, the resident requested hot soup. A CNA heated the soup in a foam cup in the microwave for approximately 45 seconds and provided it to the resident with a straw. The resident then requested crackers and a spoon, and the CNA left the room to obtain a different style of cup from the kitchen to make the soup safer to eat with a spoon. During the CNA’s absence, the resident tipped the soup bowl over, accidentally spilling the hot soup onto their lap and the floor. A nursing progress note documented redness on the resident’s anterior thighs bilaterally immediately after the spill, and the area was cleansed with silicone cream applied per the resident’s wishes. The CNA confirmed they did not use a thermometer to check the soup temperature before serving it, despite the DON stating that thermometers and signage indicating appropriate hot liquid temperatures were available by every microwave and that staff were expected to obtain temperatures of hot liquids prior to serving them. Subsequent documentation identified a desiccated blister on the right medial thigh consistent with a second-degree burn from the hot liquid spill.
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