HospitalInspections.org

Based on document review and interview, the facility failed to provide safe environment for patients by failing to make timely corrections to known issue with coffee temperature in 2 of 10 instances.
Findings include;

1. Review of P1's MR indicated the following:
a. Facility admission 1/29/24 through 2/13/24 for acute cerebral vascular accident (CVA) and hypertension (HTN).
b. Nurses note entered 2/3/24 at 6:30 am indicated P1 was burned from spilling a cup of hot coffee on his/her right leg. Medical Doctor (MD) was notified and orders received to cleanse burned area, apply ice and silver sulfadine cream.
c. Wound care note entered 2/6/24 at 2:15 pm indicated P1 had been seen at his/her dermatology office as an outpatient, where the partial thickness burn, 2nd degree, had been assessed by the dermatologist.

2. Incident report for P2, entered 1/2/24 at 4:06 pm, indicated incident occurred 12/27/23 at 8:00 am. Incident report indicated P2 spilled coffee on his/her chest. Wound care notified day of spill, and there was some redness noted. No interventions ordered. A couple days later, the skin looked like it was peeling. Plurogel was ordered.

3. Review of facility document work order indicated a work order was placed 2/4/24 at 11:17 am. In the description area read "Patient injury on 2/3/24 from hot coffee spill. Please check/adjust temperature of coffee brewed in nutrition rooms on NUR1 and NUR2." The general notes area indicated a technician looked at the coffee machines, and determined they were set to the lowest temperature setting.

4. Review of facility Operations Committee Meeting minutes, dated 2/5/24, indicated the coffee machines in patient areas were discussed. Action/Discussion section of this indicated the Facilities Management director would contact the coffee machine vendor and request the temperature be turned down. Alternative cups would be looked for. Staff would be instructed to put ice in the coffee before giving it to patients, and would ensure a lid on the cup before giving it to the patients.

5. In interview, on 5/23/24 at approximately 3:50 pm, A4 (Facilities Management Director) verified he/she called the rental company that the facility rents the coffee machines from to ask about decreasing the coffee machine temperatures. The rental company is to come next week to install a temperature regulator on the coffee machines. No visit by rental company had occurred at time of survey.