Angie SzumlinskiUncategorized

Sadly, another resident sustained burns this week after spilling a bowl of hot soup in her lap.  The resident was immediately taken to her room, her skin was checked, her clothing was changed and the staff continued with their day. The following morning the resident was identified with several blisters on her thighs.The resident had been assessed and was deemed safe to consume hot liquids independently however in this case several things went wrong. 

The facility protocol required that the temperature of hot liquids be checked at each meal and be documented on the temperature log.  The policy was followed however the temperature of the soup at point of service was 184 degrees and the soup was still served.  Although there is some difference of opinion, there is evidence that hot liquids at a temperature of 180-190 degrees F (82-88 degrees C) can cause a third degree burn in two to seven seconds.

Our staff are busy, residents are dynamic and sometimes “stuff happens” however this situation has increased risk to the facility for several reasons.  First, the hot liquid policy clearly requires dietary to check the temperature of hot foods at point of service however does not instruct the staff as to what to do if the hot liquid exceeds the safe temperature range.  Does your policy clearly identify the steps that should be taken in the event food temperatures exceed safe parameters?  Are you sure?

Second, the staff who witnessed the incident failed to notify a supervisor immediately.  This is important because skin damage due to exposure to hot liquids may not be evident immediately.  Also, the Federal regulations under Prevention of Abuse and Neglect state that direct care staff must notify their supervisor immediately if an incident occurs that has the potential to cause harm to a resident.   The staff did not follow the facility policy regarding notifying their supervisor immediately. 

Please review your facility policy regarding Hot Liquids, educate direct care staff on facility expectations and perform regular Quality Assurance audits to ensure compliance.  Hot Liquid policies and assessment tools are available on the HealthCap Risk Management website under Best Practices if you need assistance with developing a protocol for your facility.  Thank you!