Unlabeled Chemical Left in Shared Bathroom of Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that the environment remained free of accident hazards for two residents with severe cognitive impairment who shared a bathroom. During an observation, an unlabeled bottle containing a clear liquid with a strong chemical odor was found hanging on the handrail in the shared bathroom. Staff interviews revealed that no one knew the origin of the bottle, and it was unclear whether it belonged to the residents, housekeeping, or a family member. The bottle was not labeled, and staff acknowledged that chemicals should not be left in resident areas, especially in unlabeled containers. Record reviews indicated that both residents required a structured environment in a secure unit due to diagnoses of Alzheimer's disease, unspecified dementia, and cognitive communication deficits, with severely impaired cognition as evidenced by low BIMS scores. The facility's Safety Data Sheet for a disinfectant/detergent cleaner described the chemical as causing severe skin and eye burns and being harmful if swallowed or in contact with skin, with instructions to store it locked up. The facility did not have a specific policy on labeling chemicals or keeping them out of resident rooms, contributing to the deficiency.