Burn Injury from Hot Coffee Due to Lack of System for Safe Hot Liquid Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to hot liquids, resulting in a resident sustaining burns from spilled coffee. The resident had diagnoses including dementia, aspiration pneumonia, dysphagia, and insomnia, and a quarterly MDS identified severe cognitive impairment with a need for setup or cleanup assistance for eating. The care plan documented a self-care deficit related to dementia, poor coordination, and weakness, and indicated the resident was independent with eating but required supervision and cueing at times. The nursing assistant care guide specified that the resident should receive coffee only in a covered mug with cooled coffee and no styrofoam cups. Despite these documented needs and instructions, the resident experienced multiple coffee-related incidents. Progress notes showed that on one earlier occasion the resident spilled coffee on his left foot, causing a burn with minimal redness. Later, the resident again spilled coffee while drinking in his room, resulting in a large reddened area on the left side of his body, including the forearm and abdomen, with peeling skin and subsequent documentation of first- and second-degree burns. Staff noted that the resident would not allow them to touch the affected areas and that pain medication and cold packs were required, with ongoing monitoring and treatment ordered by the NP and physician. Surveyor interviews and observations revealed systemic gaps in how hot beverages were prepared and served. Coffee for early-morning service was brewed in the activity kitchen while the main kitchen was closed, and the dietary manager measured coffee in a cup at 170°F. Staff practices for determining which residents required lids or cooled liquids were inconsistent; some CNAs relied on asking the charge nurse, some believed this should be in the care plan, and one CNA who served the resident on the day of the burn was unaware of the requirement for a specific handled cup with lid and had not seen the care sheet indicating no styrofoam cups. The DON acknowledged there was no policy on safe serving temperatures for hot liquids and no assessment tool to determine which residents were safe to receive hot liquids, while CNAs reported informal methods such as adding cold water or ice and noted that several residents with dementia drank coffee without being identified as needing cooled beverages.
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