Failure to Prevent Resident Access to Hazardous Chemicals Resulting in Bleach Ingestion
Penalty
Summary
A resident with a history of Parkinson's disease, anxiety disorder, hypertension, obesity, and liver abscess was admitted to the facility and exhibited signs of cognitive impairment, including wandering, attempts to leave the facility, and confusion regarding orientation. Despite these behaviors and documentation of impaired cognition, there was no care plan addressing cognitive impairment until more than two years after admission. The resident was known to wander into other residents' rooms and had difficulty with redirection, sometimes becoming combative with staff. On one occasion, the resident ingested bleach after filling a container that previously held bleach wipes with water and drinking from it, mistaking it for his water cup. The incident was discovered after the resident's roommate reported the behavior, and the resident himself indicated confusion between the bleach container and his water cup. The bleach wipe container was found accessible in the resident's room, and staff interviews confirmed that such containers should not be left within reach of residents, especially those with cognitive impairment. Further review revealed that the facility did not have a specific policy for chemical storage, relying instead on a general safety and supervision policy. Observations confirmed that cleaning wipe containers were accessible in resident rooms, and staff acknowledged that hazardous chemicals should be stored securely and not left in areas accessible to residents. The facility's policy emphasized the importance of identifying and mitigating accident hazards, but in practice, hazardous materials were not consistently secured, leading to the resident's accidental ingestion of bleach.