Failure to Prevent Resident Access to Hazardous Substances and Inadequate Supervision
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for several residents. Specifically, staff did not properly store hand sanitizer, resulting in a resident with severe cognitive impairment drinking an unknown amount of hand sanitizer and requiring hospital evaluation. The hand sanitizer was left accessible in the dining room, and staff interviews revealed uncertainty about who was responsible for its placement and a lack of knowledge regarding proper storage protocols. Multiple staff members, including CNAs, LVNs, and housekeeping, reported not receiving training on what to do if a resident ingests a harmful substance or chemical, and some were unaware of the incident or the resident's behavioral risks. In addition to the hand sanitizer incident, the facility failed to provide adequate supervision in the dining room, allowing two separate residents to drink the saliva of another resident from her spit cup. These incidents were not documented in the residents' progress notes or incident reports, and staff interviews indicated that these behaviors had occurred previously but were not consistently reported or addressed. The care plans for the involved residents identified behavioral risks, such as eating or drinking inedible items and aggressive behaviors, but interventions such as increased monitoring and 15-minute checks were not effectively implemented or communicated to all staff. Observations during the survey found hand sanitizer bottles stored in accessible areas, such as a shower room, and staff were unclear about official storage locations. Interviews with management and staff revealed a lack of consistent training and communication regarding hazardous substance management and resident supervision. The facility's failure to maintain a safe environment and provide adequate supervision placed residents at risk of harm, as evidenced by the ingestion of hand sanitizer and saliva by cognitively impaired residents.