F0689

G

Resident Burn from Unsafe Hot Beverage Temperature

Port Angeles, Washington Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The facility failed to ensure hot water used for beverages was at a safe temperature and adequately supervised, resulting in a burn injury to one resident. A cognitively intact resident requested a cup of hot chocolate from the kitchen. A dietary aide filled a cup directly from the hot water dispensing machine, added hot chocolate mix, placed a plastic lid on the cup, and handed it to the resident without checking the water temperature. The resident then placed the cup in their lap while in a motorized wheelchair and went outside. The resident later reported that the hot liquid spilled through the straw hole in the lid onto their abdomen.

Subsequent nursing assessment documented a burn measuring 10 cm long by 2.5 cm wide with blistering at the midline of the resident’s abdomen, and the resident reported some pain. The wound care nurse later acknowledged that the burn was consistent with a partial-thickness (Stage 2) burn. During the survey, the hot water dispensing machine was observed to produce water at 180.1°F. The dietary director stated that the machine had always produced 180°F water and described a practice of filling carafes and allowing them to cool to 140°F, or adding ice cubes if carafes were not available. The dietary aide involved stated they became busy and forgot to check the temperature of the hot cocoa before serving it and also noted that cups became warped in the dishwasher and lids did not always fit correctly.