Resident Ingests Cleaning Solution Due to Improper Chemical Storage
Penalty
Summary
A deficiency occurred when a housekeeper left a cleaning solution in an unlabeled, clear disposable cup on a resident's bedside table. The resident, who had diagnoses including end-stage renal disease, heart failure, and a recent non-ST elevation myocardial infarction, returned to his room after being outside and drank from the cup, believing it contained water. Upon tasting the liquid, the resident immediately recognized it was not water, attempted to induce vomiting, and called for assistance. The cleaning solution was a heavy-duty multi-surface cleaner, which, according to its safety data sheet, can cause serious eye damage, skin irritation, and gastrointestinal symptoms if ingested. The incident was confirmed through multiple sources, including the resident's own account, nursing notes, emergency department records, and interviews with facility staff. The housekeeper admitted to pouring the cleaning solution into a disposable cup due to the lack of an appropriate bottle and left it unattended on the bedside table. The facility's policies required chemicals to be stored in properly labeled containers and prohibited the use of unlabeled containers for hazardous substances. However, the housekeeper was not trained on this policy until after the incident, and the required labeling and storage procedures were not followed at the time of the event. As a result of ingesting the cleaning solution, the resident experienced mouth and throat irritation, tingling, and discomfort, and was transferred to a general acute care hospital for evaluation and treatment. The resident reported ongoing symptoms, including blisters and irritation when swallowing, and was referred for an ENT consult. The facility's failure to ensure chemicals were stored and labeled according to policy directly led to the resident's accidental ingestion and subsequent health complications.