Burn Injury from Overheated Coffee and Lack of Hot-Liquid Safety Process
Penalty
Summary
The deficiency involves the facility’s failure to ensure hot liquids were provided at a safe drinking temperature, resulting in a resident sustaining burn injuries. The facility’s policy titled “Free of Hazards/Supervision and Devices” required an interdisciplinary approach to identify, evaluate, and mitigate risks to maintain resident safety. Washington State Department of Labor and Industries guidance indicated that water at 155°F can cause a third-degree burn in one second. Despite this, dietary staff reported they ensured brewed coffee was at 155°F before taking the coffee cart to resident areas and kept logs to make sure it was not over 155°F. Resident 1, who had quadriplegia, heart failure, anxiety, intact cognition, and required set-up assistance for eating and dependence for other ADLs, reported spilling hot coffee on their lap. Due to decreased sensation in their legs, the resident did not feel the burn and did not report the incident immediately. A nursing progress note documented an area of redness on the right thigh measuring 4.5 cm by 13.0 cm with multiple fluid-filled blisters, and the facility’s investigation noted a red area with blisters after the resident stated they had spilled a hot beverage earlier in the day and forgotten about it until nighttime care. Surveyor observation showed the resident seated in a common area with a cup of coffee with a lid on the table and a sweatshirt over their lap, and the resident stated they had obtained coffee from the front coffee station with assistance from someone else. During the survey, the DON measured coffee from a pot on the coffee cart in the common area and found it to be 168.8°F, with visible steam rising from the cup. The dietary manager later confirmed that staff were only checking the temperature of one of four coffee pots before leaving the kitchen and were unsure whether temperatures were taken directly from the pot or from a pitcher. The DON and administrator acknowledged that there was no process or assessments in place to ensure residents were safe in handling hot liquids, and that staff were expected to check coffee temperatures before sending and before serving, but this was not being carried out as described.
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