Resident Ingests Non-Consumable Item Due to Inadequate Supervision
Penalty
Summary
Seton Manor Nursing and Rehabilitation Center was found to be non-compliant with federal and state regulations regarding accident hazards and supervision. The deficiency was identified on the Cloister nursing unit, a locked dementia unit, where a resident with cognitive impairment and behavioral disturbances was able to access and ingest a non-consumable item. The resident, who had a history of dementia with anxiety and depression, was independently ambulatory and known to enter other residents' rooms. On January 23, 2025, the resident ingested Derma/Vera, a skin and hair cleanser, after being found with the bottle in the activity room. Observations on January 28, 2025, revealed that personal hygiene items, including skin cleansers and lotions, were left accessible in various resident rooms on the Cloister unit. These items were found on bathroom counters and in open closets, with bathroom doors left open, allowing the resident to ambulate near these areas. The Director of Nursing and Assistant Director of Nursing acknowledged that personal hygiene items should have been kept out of reach of confused residents, indicating a failure to maintain a safe environment free of accident hazards.
Plan Of Correction
1) R1 has not had any further incidents involving attempting to ingest non-edible objects/non-consumable items. 2) Room audits will be conducted on the cloister (locked) unit for assessable non-edible/non-consumable items. 3) All staff will be educated on securing non-edible/non-consumable items out of reach of confused residents. 4) NHA/designee will complete random audits daily for 7 days, weekly for 3 weeks. Results will be tracked and trended and reported to QAPI committee.