F0689

G

Failure to Safely Serve Hot Liquids Resulting in Resident Burn

Prophetstown, Illinois Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure hot liquids were safely served and to have an effective process in place for hot liquids, resulting in a resident sustaining burns from spilled coffee. The resident had multiple diagnoses including acute and chronic respiratory failure with hypoxia, atherosclerotic heart disease, dysphagia, epilepsy, hemiplegia/hemiparesis, and mononeuropathy of the left lower limb. Facility assessments and care plans documented that the resident had no cognitive impairment but required substantial to maximum assistance for most cares, had hemiplegia and left-side neglect from a prior CVA, limited strength and mobility on the left side due to a chronic left rotator cuff tear and shoulder masses, and a swallowing problem with loss of food/liquids from the mouth. The care plan also noted that the resident had moderate spillage of food and fluids, would fall asleep or become distracted during meals, and would remove lids from cups causing liquids to spill.

On the morning of the incident, nursing documentation showed that the resident spilled hot coffee on the left knee during breakfast, resulting in a red area measuring approximately 5 inches by 3 inches on the inner left knee and reported pain level of 5, for which PRN Tylenol was given. A skin check the same day documented a new in-house acquired burn to the front left knee measuring 12.5 cm by 7.5 cm. Subsequent observation of the wound revealed triangular and oval open areas on the inner left knee where fluid-filled blisters had burst. The resident reported that he had been trying to turn his short metal insulated coffee cup with a plastic lid so the drinking hole was in position, fumbled the cup, and the coffee poured out of the small hole onto his leg. Staff interviews indicated that the resident could not turn the lid himself due to only having use of his right arm and might have placed the cup between his knees while attempting to turn the lid.

The facility’s hot liquid safety policy required that hot liquid temperatures be checked in the dietary department prior to distribution and that residents with difficulties receive appropriate supervision and assistive devices, with individualized interventions on the care plan. However, the dietary aide stated that they did not perform temperature checks on coffee, and a CNA reported never being asked to check coffee temperatures before serving. The dietary manager stated that typically coffee was poured, lidded, and placed on the cart without routinely checking temperatures, and that any temperature checks were random and infrequent, with no clear documentation process. During observation, the dietary manager measured coffee at 164°F, then diluted it to 147°F before sending it to the unit, and acknowledged that hot liquids posed burn risks, especially for residents with neurological impairments who might not be able to hold cups. These actions and inactions demonstrate that the facility did not consistently implement its hot liquid safety policy or ensure safe serving practices for hot beverages for this resident.