F0689

G

Failure to Monitor Hot Liquid Temperature Resulting in Resident Burns

Hiawatha, Kansas Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision related to hot liquid service, resulting in a cognitively impaired resident sustaining burns from spilled coffee. The resident had diagnoses including generalized muscle weakness, dementia, dysphagia, and a cognitive communication deficit, with MDS assessments documenting progression from moderate to severe cognitive impairment. Care plans and a prior hot liquids safety evaluation identified the need for specific interventions with hot liquids, including use of a cup with a lid, non-spill thermal mug if accepted, clothing protector over the chest and lap, consumption of hot liquids only at the table or with staff supervision, and addition of ice cubes to hot beverages and soups per family request.

On the day of the incident, the resident was seated in the dining room for breakfast and requested a second cup of coffee. Dietary staff refilled the resident’s metal coffee cup, added sweetener, placed the lid on the cup, and returned it to the resident without confirming whether the coffee temperature was within the facility’s stated safe range. Shortly thereafter, staff in the serving room heard the resident holler and observed coffee on the floor. A CNA checked on the resident and found coffee on the resident’s lap, began to pat it dry, and requested a nurse to assess the resident. The nurse’s assessment documented erythema from below the belt line to the groin, pain in the groin and bilateral thighs, and blistering on the inner thighs consistent with a burn injury.

Following the spill, dietary staff measured the remaining coffee in the resident’s cup and recorded a temperature of 151°F. An Emergency Department note documented that the resident had eaten breakfast, spilled coffee in her lap, and was later found during showering to have significant firmness and peeling skin in the lap area. The burn center admission note documented partial thickness scald burns to the bilateral thighs and perineum after spilling coffee measured at 157°F in her lap. Facility staff interviews indicated that dietary staff were expected to obtain the temperature of every cup of hot liquid and not serve it if it exceeded 135°F, and that a list existed to direct which residents required lids and other hot liquid interventions. However, the dietary staff member who refilled the second cup of coffee for the resident could not recall obtaining the temperature before serving it, and another dietary staff member acknowledged that the temperature of the second cup had not been checked, leading to the resident being served excessively hot coffee that spilled and caused the documented burn injuries.

The facility’s own reportable investigation concluded that the incident was accidental and related to the resident’s health condition, noting that the resident had a lid on her coffee cup per her care plan but dropped the cup and the lid came off. The investigation also documented that the resident had no prior history of dropping her coffee. Despite existing care plan interventions and a hot liquid safety evaluation specifying the need for controlled hot liquid service and supervision, the failure to verify the temperature of the second cup of coffee before serving it, combined with the resident’s cognitive impairment and physical limitations, resulted in the resident being exposed to a hot liquid hazard and sustaining second-degree burns to the inner groin and bilateral thighs.