F0689

G

Failure to Assess and Protect Resident From Hot Liquid Burn

Wabasso, Minnesota Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents related to hot liquids and to have an effective system to assess residents’ safety with hot liquids. A cognitively intact resident with diagnoses including diabetes, peripheral neuropathy, malnutrition, and anxiety was independently ambulatory with a walker and independent with eating. The resident’s care plan initially identified independence with eating, and only after the incident was a revision made to specify that staff should ensure the lid was on and secure for hot liquids. At the time of the incident, there was no documented individualized assessment or care plan intervention addressing the resident’s ability to safely handle hot liquids despite her peripheral neuropathy and other comorbidities.

On the day of the incident, the resident was having lunch when hot water from a plastic thermal mug spilled onto her upper right thigh. The resident later reported that the lid was not sitting correctly on the mug and popped off, causing hot water to splash onto her hand, startling her and leading her to jerk, which caused the remaining hot water to spill onto her right thigh. She stated that the hot water soaked through her sweatpants and into her incontinent brief, burning most of the top of her right thigh and the right groin fold. The resident reported experiencing horrible pain and stated it took 20–30 minutes for a nurse to come while she struggled to remove her clothing. A nursing assistant confirmed being notified by dietary staff that the resident had spilled hot water, immediately taking her back to her room, and then leaving to find the charge nurse, describing the resident’s leg as a large, very red area with a forming blister and noting the resident’s significant pain and frustration.

Clinical documentation following the incident showed that the initial nursing note described visible redness to the upper thigh, with education provided to the resident to be careful with hot liquids and to ask for help. The physician ordered Vaseline and pain medication. The following day, documentation identified a reddened area with a blister approximately five inches by three inches, and orders were obtained for Xeroform and dressings. A subsequent wound note documented a partial thickness burn acquired in the facility, but the measurements recorded were later verified as incorrect. The resident’s primary care provider’s visit note from the day after the incident did not mention the thigh burn, describing the skin as warm and dry with no rashes or lesions on exposed skin. Later documentation identified the burn as a stage 2 burn site requiring debridement and daily wound care. A hospital wound care consult subsequently measured the burn at 15 x 26 x 0.1 cm and described it as a partial thickness burn that was blistered, fragile, bleeding, and erythematous. Staff interviews revealed that prior to this incident, the facility had not been conducting hot water assessments on residents, and there was inconsistency in staff accounts regarding the existence and implementation of a hot liquid policy and temperature monitoring at the time the resident was burned.

Additional staff interviews highlighted issues related to hot liquid temperatures and supervision. The dining specialist stated that all hot water and coffee were served from the kitchen and that the water was too hot, noting that on the day of the interview the temperature was being turned down. She reported being on duty when the resident was burned but did not know who provided the hot water, and she assumed, based on the severity of the burn, that the water had been way too hot. The certified dietary manager reported that a dietary staff member reheated the water in the microwave and stated that the water was reportedly 138°F when checked, with staff expected to log temperatures. The facility’s hot liquid safety policy, implemented prior to the incident, required assessment of all residents for their ability to handle containers and consume hot liquids, with individualized interventions on the care plan, and described the time–temperature relationship for serious burns, including that at 133°F a third-degree burn could occur in 15 seconds and at 140°F in 5 seconds. Despite this policy, interviews and documentation showed that residents had not been systematically assessed for hot liquid safety and that the resident involved in the incident did not have appropriate hot liquid precautions in place at the time of the burn.