Failure to Control Hot Liquid Temperatures Resulting in Resident Burns
Penalty
Summary
The facility failed to ensure hot liquids were served at a safe temperature and that residents at risk for burns were adequately protected, resulting in burns to two residents. One resident with vascular dementia, behavioral disturbance, unspecified psychosis, and mildly impaired vision, and who was unable to complete a BIMS interview (score 99), was observed sitting alone at a table drinking from a brown coffee cup without a lid. This resident later sustained scalding burns to both thighs and a blister on the left thigh after spilling a hot fluid, with the physician describing the injury as 99% first-degree and 1% second-degree burns. The resident’s care plan included an intervention to ensure awareness of hot liquids and to provide lids as needed, but no lid was observed in use. A state incident report documented the hot fluid spill and resulting burns. A subsequent surveyor temperature check of coffee measured 160.9°F, and food temperature records showed coffee holding temperatures of 180°F on two dates, despite a facility policy stating that hot liquids above 140°F should be held in dietary until they reached an appropriate temperature. A second resident, who was cognitively intact (BIMS 13) but had diagnoses including unspecified convulsions, reduced mobility, impaired cognitive functions and awareness, and muscle weakness, and who was receiving propranolol for tremors, was also observed drinking from a brown coffee cup without a lid. This resident had previously reported spilling hot tea on their lap before breakfast, resulting in a wound measuring 6.0 x 2.5 inches with a blistered area of 4.0 x 1.5 inches; a physician later classified this as a second-degree burn, with updated wound measurements of 6 cm x 2 cm x 0.1 cm. A surveyor-measured hot water temperature was 166.9°F. The assistant director of nursing identified four residents at risk for burns from hot liquids. The cook stated they did not take temperatures of coffee or tea before serving and simply provided drinks to CNAs, and the dietary manager reported not knowing the policy for serving hot liquids, indicating that the facility’s written hot liquid safety policy was not being followed in practice.
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