F0689

G

Failure to Monitor Hot Beverage Temperatures Resulting in Resident Burns

Lititz, Pennsylvania Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The facility failed to ensure staff monitored and controlled the temperature of hot liquids served to residents, resulting in burn injuries to one resident. Facility policy on Safety of Hot Liquids required hot liquid serving temperatures to be maintained at no more than 180°F, and a procedure directed that liquids heated in the microwave be limited to 6 ounces per one beverage cycle. Despite this, a CNA prepared approximately 8–10 ounces of water in a ceramic mug from the ice and water machine, heated it in the microwave for two minutes, then added four packets of honey and a tea bag before serving it to a resident. The temperature of the beverage was not checked. The incident occurred after kitchen hours when no dietary staff were present, and the DON reported that food and beverages prepared by non-dietary staff after hours were not temperature-checked. A subsequent reenactment using 8 ounces of cold water heated for two minutes in the same type of mug showed a temperature of 187.6°F, exceeding the facility’s stated maximum serving temperature.

The resident involved, who had diagnoses including congestive heart failure and muscle wasting/atrophy, had a BIMS score of 15 indicating intact cognition and was documented as independent with eating, though an occupational therapy note indicated a need for set-up and clean-up assistance for meals. On the evening of the incident, the resident requested pretzels, hot tea, and honey. After the CNA placed the hot tea and pretzels on the bedside table, the resident used the recliner remote to raise the chair to move closer to the table, caught the bottom of the bedside table, and upended it, spilling the hot tea onto the right chest and right hip area. A nursing progress note documented slightly red skin with a thin layer of skin peeling off immediately after the spill. A wound specialist’s evaluation five days later identified two burn wounds: a full-thickness wound on the right posterior thigh measuring 13.7 cm x 5 cm with unmeasurable depth due to tissue overgrowth, and a wound on the right chest measuring 4 cm x 5.6 cm with unmeasurable depth due to tissue overgrowth. The DON’s investigative report confirmed the resident was provided hot tea of unknown temperature, and both the DON and NHA acknowledged the resident received a hot beverage of unknown temperature resulting in multiple burn injuries.