Improper Chemical Labeling and Storage Leads to Residents Being Served Sanitizer
Penalty
Summary
A deficiency occurred when the facility failed to implement safe and sanitary food handling practices in the kitchen, specifically by not ensuring that hazardous chemical cleaning and sanitizing solutions were properly labeled, stored, and used according to manufacturer instructions and facility policy. A cook, who had not received any documented orientation or training, used a clear plastic drink pitcher to mix a red sanitizing chemical solution due to a lack of available sanitation buckets. After cleaning, the cook left the pitcher containing the chemical in the sink, and it was later mistaken for pink lemonade by another staff member, who then served it to residents on the East unit. Ten residents were served the chemical solution, and the facility could not determine how much was consumed by each individual. The affected residents included individuals with chronic kidney disease, dementia, cerebral infarction, COPD, and cerebral palsy, with varying levels of cognitive impairment. One resident experienced vomiting after lunch, and all affected residents were assessed for symptoms, with physicians and poison control notified. However, clinical record reviews revealed that the ordered monitoring, fluid administration, and oral assessments were not documented as completed at the time of the incident for any of the residents involved. Interviews with dietary staff and review of personnel files showed that most kitchen staff were newly hired and had not received formal education or training regarding their job responsibilities, chemical safety, or labeling procedures. The contracted dietary company did not provide written job descriptions or documented orientation for the staff. The lack of proper labeling, storage, and staff training directly led to the accidental serving of a hazardous chemical to residents, resulting in Immediate Jeopardy to resident health and safety.
Plan Of Correction
Investigation was completed on 9/22/2025. Root cause determined to be isolated staff member improperly using a drink pitcher to store a cleaning sanitizer. Medical team made aware. Poison Control Center consulted. East Unit residents were assessed, and additional orders were implemented for the 10 residents found to have ingested some of the diluted sanitizer. These orders included vital sign monitoring, additional fluids, and oral assessments. Resident Representatives notified. Completed on 9/22/2025. DON/designee to complete follow-up clinical needs determined by post-incident evaluations of affected residents. Completed on 9/23/2025. The chemicals in the kitchen were reviewed for proper storage and labeling; sanitizing solutions were secured. Dietary staff are to store drink pitchers on the shelf under the beverage preparation station. Open chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Dietary Manager/designee to complete post-education audits to ensure compliance with remediation. Audits to be completed 5 times weekly for 4 weeks. Audit findings to be reviewed at the facility QAPI. Audits initiated on 10/3/2025 and continue. DON/designee to complete post-education audits to ensure compliance with remediation. Audits to be completed 5 times weekly for 4 weeks. Audit findings to be reviewed at the facility QAPI. Audits initiated on 10/3/2025 and continue.
Removal Plan
- A root-cause analysis determined that a staff member had improperly used a drink pitcher to mix and store a sanitizing chemical in the kitchen.
- All residents on the East Unit were reassessed for injury or adverse effects, and physician orders were implemented for care and monitoring.
- All chemicals in the kitchen were reviewed for proper labeling and storage.
- Education was provided to all dietary and nursing staff regarding chemical safety, labeling, and segregation of food and cleaning supplies.
- All chemicals not in active use were removed from the kitchen area and placed in a secure, designated chemical-storage area.
- Facility dietary policies regarding chemical labeling, storage, and use were reviewed and revised.
- Post-education audits were initiated to verify continued staff compliance with labeling and storage procedures.