Failure to Investigate and Document Resident Exposure to Toxic Chemical
Penalty
Summary
The facility failed to investigate and document an incident in which residents were exposed to a toxic chemical in the dining room. According to the facility's policy, any incident or accident that could result in physical harm or emotional upset must be documented in the resident's medical record, and a nursing assessment should be completed. On the date of the incident, a registered nurse accidentally discharged a can of a chemical substance in the dining room, causing residents and staff to cough and experience eye irritation. Residents were evacuated, and emergency services were called, but no nursing assessments were performed or documented for the residents involved, including a cognitively intact resident who reported symptoms but was not assessed by a nurse. Multiple staff members, including RNs and an LPN, confirmed that no incident reports, resident assessments, or investigations were completed following the exposure. The Director of Nursing acknowledged that nursing assessments should have been completed and documented but were not. The facility was unable to identify which residents were present in the dining room at the time of the incident and could not provide any documentation of an investigation, witness statements, or incident reports related to the event.