Failure to Secure Hazardous Chemicals Resulting in Resident Ingestion
Penalty
Summary
The facility failed to secure hazardous chemicals and prevent access by residents with cognitive impairment, resulting in an incident where a resident with Alzheimer's disease and moderate cognitive impairment ingested a hydrogen peroxide-based cleaning solution. The resident, who had a history of behavioral indicators of drinking cleaning chemicals, was able to access a spray bottle of disinfectant that had been left unattended on a housekeeping cart outside the janitor's closet. The bottle's lid was off, and the resident was observed with the bottle up to their mouth, taking some of the solution into their mouth and then spitting it out. The resident vomited once after breakfast but did not report any complaints or suffer further ill effects. Staff interviews and documentation confirmed that the housekeeping cart containing cleaning chemicals was left out and unattended, contrary to facility policy requiring chemicals to be stored in secure, locked areas when not in use. The incident was observed by a treatment nurse, and the event was reported to the medical director. The facility's care plan for the resident had previously identified the risk of ingesting cleaning chemicals, but the failure to secure the cart allowed the resident access to the hazardous substance.