F0689

J

Failure to Control Hot Coffee Hazard and Supervise Residents, Resulting in Burn Injury

Picayune, Mississippi Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to keep the resident environment free from accident hazards and to provide adequate supervision related to hot liquids, resulting in a resident sustaining a burn from hot coffee. On 12/31/25 at approximately 3:40 PM, a resident with dementia and a severely impaired BIMS score of 03 received hot coffee from another resident in the dining area. The coffee spilled onto the resident’s left thigh/hip area, causing pain and visible blistering. Staff documentation and progress notes identified a new in-house skin issue on the front left trochanter, described as a blister measuring approximately 7.06 cm by 7.56 cm, and the facility’s Medical Director later confirmed this as a second-degree thermal injury from hot coffee.

At the time of the incident and in the days following, the facility did not implement environmental controls or supervision to prevent other residents from exposure to the same hot coffee hazard. The facility’s own “Safety of Hot Liquids” policy required hot liquids to be served at safe temperatures, not more than 140°F, with appropriate safety precautions such as staff supervision or assistance and regulation of temperatures for liquids to which residents had direct access. However, review of the facility’s Hot/Cold Holding Temperature Log (coffee logs) showed no coffee temperatures were recorded prior to 1/6/26. Observations on 1/12/26 at 7:20 AM revealed a coffee machine in the dining area that remained plugged in, operational, and accessible to residents, despite being labeled “out of service.” The State Agency was able to obtain hot coffee from this machine without staff assistance or intervention while residents were present and no staff were supervising or restricting access, and there were no physical barriers to prevent resident use.

Interviews with facility leadership and staff further demonstrated inaction and lack of timely response to the identified hazard. The DON stated that the incident occurred when one resident provided hot coffee to the cognitively impaired resident, resulting in the burn, and confirmed that she did not become aware of the incident until 1/2/26. She acknowledged that after learning of the burn, no immediate corrective or preventive measures were implemented to reduce the risk of other residents sustaining burns from hot liquids, and that resident access to coffee machines continued without restriction, supervision, or temperature control between 12/31/25 and 1/6/26. The Administrator reported he was not informed of the burn incident until a stand-up meeting on 1/6/26 and confirmed that, even after leadership discussed modifying the coffee service process, he did not verify that any changes were implemented or monitored. A cognitively intact resident reported that residents continued to obtain coffee directly from the machines and that staff did not consistently unplug them, corroborating that residents had ongoing access to hot coffee in violation of the facility’s safety and supervision policies.

The facility’s “Safety and Supervision of Residents” policy stated that the environment should be as free from accident hazards as possible, that safety risks and environmental hazards would be identified on an ongoing basis, and that the QAPI/Safety Committee would evaluate hazards and develop strategies to mitigate or remove them. It also required the interdisciplinary team to identify specific accident hazards for individual residents and to implement and communicate targeted interventions, including adequate supervision. Despite these written expectations, the facility did not identify the hot coffee machines as an ongoing environmental hazard after the burn incident, did not promptly analyze or address the risk for other residents, and did not implement or enforce supervision, access restrictions, or temperature regulation for hot coffee until after the State Agency’s on-site observations.

Resident #1’s medical record also showed that the burn had been present and under treatment for several days before the family requested an Emergency Department evaluation, where the history documented that the patient had been burned at the nursing home from a coffee spill about a week earlier. This further supports that the burn was recognized and being treated in-house while the underlying environmental hazard—resident access to excessively hot coffee from accessible machines in the dining room—remained unmitigated. The combination of the initial incident, the lack of timely hazard recognition and control, and the continued availability of hot coffee without supervision or temperature monitoring constituted the deficient practice under 42 CFR §483.25(d)(2) related to accidents and hazards.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created to indicate the staff member who tested the temperature of the coffee and the time.
• Coffee temperature logs will be turned into the Administrator daily.
• Training for all staff prior to their next scheduled shift.
• No staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse (Accidents and Supervision including implementing immediate interventions; Abuse and Neglect Reporting and Investigation; Hot Liquids Policy; Notification of Administrator and DON of unusual occurrences/high risk events and timely notification; Charge Nurse Delegation and Duties including assignment of charge nurse; Medication Administration Documentation).
• All residents were evaluated for safety with hot liquids by nursing leadership and RNs.
• Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
• The Facility Assessment was updated to include a contingency plan for absence of supervisory nursing staff and to adequately identify staffing needs by shift and building.
• The facility's Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
• The Scheduler and the Staff Development Nurse were inserviced by the DON on the new Assignment Grid and Charge Nurse Delegation.
• The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
• If the assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment.
• The DON and Administrator's phone numbers are posted on the Facility Assignment Grid.
• In the event that the charge nurse is impaired, the DON and Administrator will be contacted.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
• An emergency Quality Assessment and Assurance Committee meeting was held to review the Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy and discuss incidents/actions taken including training and monitoring.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving an LPN.
• An LPN was reported to the agency that she works for and is not allowed to work at this facility.