Immediate Jeopardy: Hazardous Chemical Served to Residents Due to Administrative Oversight
Penalty
Summary
The facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental well-being of residents. Specifically, the administration did not ensure resident safety when the dietary department served a hazardous cleaning chemical to residents during meal service. As a result, ten out of fifty-seven residents ingested the chemical, placing all residents in the East Wing at risk of consuming a hazardous substance and resulting in an immediate jeopardy to resident health and safety. A review of the job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that their responsibilities include overseeing the safety and cleanliness of the facility, ensuring hazardous conditions are addressed, and monitoring departmental operations. The facility failed to carry out these administrative responsibilities, as evidenced by the lack of effective oversight in the safe handling, storage, and labeling of hazardous chemicals within the dietary department. Interviews with staff confirmed that dietary personnel had not received effective training or competency evaluation regarding the safe handling, storage, and labeling of hazardous chemicals in accordance with facility policy and procedure. This lack of oversight and resource utilization by the Administrator and DON contributed to the immediate jeopardy situation, as they did not monitor departmental operations, identify systemic risks, or ensure the implementation of facility policies to maintain resident safety.
Plan Of Correction
Unable to retro correct deficient practice. 2. NHA/ designee will direct and lead and direct the overall operations of the facility and ensure that the Corporate Dietary Service manager provided education to all dietary staff on proper use and storage of kitchen chemicals. NHA will ensure that Corporate Dietary Service manager/ designee is present in the facility to inspect, direct and oversee the dietary personnel to ensure regulatory compliance. In the absence of the NHA, DON will assume these responsibilities. 3. Regional Director of Operations/ designee will provide education to the NHA and DON on Administrative Duties and responsibilities. 4. Regional Director of Operations/designee will follow-up weekly by reviewing audits to ensure the NHA and DON are providing effective and efficient administrative oversight. Audit findings will be reviewed at facility QAPI meeting.