Burn Injury from Unchecked Hot Coffee Temperature
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision when serving hot beverages to a resident who required set-up assistance with meals. Facility policy titled “Microwave Safety for Hot Liquids” required that any liquids heated in the microwave have their temperature checked with a thermometer, with an acceptable serving range of 135–155°F. Despite posted reheating instructions and thermometers available near the microwaves, a staff member reheated coffee in a microwave for a resident and did not check the temperature with a thermometer before serving it, contrary to facility policy and expectations. The resident involved had been admitted with diagnoses including lung cancer, congestive heart failure, and chronic respiratory failure, and was on hospice services. An Annual MDS assessment and the resident’s plan of care indicated the resident required set-up assistance for eating. On the day of the incident, the resident was seated in a chair at the bedside when a CNA delivered a supper tray and a cup of coffee that had been reheated in the microwave. The resident refused the supper tray but requested the coffee. While the CNA was removing the supper tray and placing the hot coffee on the tray table, she accidentally bumped the tray table, causing the contents of the cup to spill onto the resident’s upper thighs. Immediately after the spill, nursing staff assessed the resident and initially observed red, blanchable skin on the upper thighs. Subsequent evaluation by a wound physician documented a cluster of second-degree burns on the right thigh and additional first- and second-degree burns on the right and left thighs, requiring daily treatment with silver sulfadiazine cream until healed. Interviews with the CNA, ADON, and DON confirmed that the CNA did not use a thermometer to check the temperature of the reheated coffee before serving it, and that this was not in accordance with the facility’s microwave safety policy and reheating guidelines.
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