Failure to Secure Hazardous Chemicals Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that hazardous chemicals were properly stored in secured areas and kept out of the reach of residents. Multiple observations and staff interviews revealed that cleaning chemicals, germicidal wipes, mouthwash, and other potentially harmful substances were found unsecured in resident rooms, common areas, and unlocked storage rooms. These chemicals were accessible to residents, despite facility policies requiring that such items be locked away when not in use. Several doors to storage rooms containing hazardous materials were found unlocked or with malfunctioning locks, and chemicals were left unattended on housekeeping carts and countertops. A resident with a history of compulsive behaviors, poor decision-making, and mental health issues, including schizophrenia with disorganized thoughts and paranoia, was able to access and apply hazardous chemicals to his body on multiple occasions. The resident had previously been found with wound cleanser, scissors, and various cleaning chemicals in his room, and had a documented pattern of taking unsafe items from around the facility. On two separate incidents, the resident applied cleaning chemicals to his feet and peri-area, resulting in second-degree chemical burns and subsequent hospitalization, including admission to a burn unit and later to the ICU for sepsis evaluation. Staff discovered the incidents after responding to the resident's complaints of pain and upon finding chemical containers in the resident's room. Medical records and staff interviews confirmed that the resident required 24-hour supervision, had a care plan noting self-harm behaviors, and had previously been redirected for taking unsafe items. Despite these known risks, hazardous chemicals remained accessible in the environment, and staff were not consistently ensuring that chemicals were secured. The facility's failure to secure hazardous chemicals directly resulted in serious physical harm to the resident, including chemical burns and hospitalization.
Removal Plan
- Hold a Quality Assurance and Performance Improvement (QAPI) meeting.
- Search the facility for unsecured hazardous chemicals and secure any found.
- Remove spray bottles of bleach solution and odor control from public bathrooms.
- Remove odor control and multi surface peroxide from nurses' stations, resident rooms, activity room, and common sitting areas.
- Relocate spray bottles of odor control, multi surface peroxide, floor cleaner, and bleach solution from the top of housekeeping carts into a locking compartment on each cart.
- Conduct a facility wide audit to ensure all hazardous chemicals are properly stored, supply room doors and cabinets are locked, housekeeping carts are locked, and all hazardous chemicals are secured within the housekeeping cart if not in use.
- Complete skin assessments on all residents.
- Complete door audits to ensure all hazardous material storage rooms have properly functioning doors and that the doors lock securely.
- Educate all staff on policies related to chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured.
- Educate any staff not yet educated at the start of their first scheduled shift.
- Educate new hires during new hire orientation on chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured.
- Conduct random audits with staff to ensure understanding of where to find pertinent policies to ensure the safe storage of harmful chemicals. Reeducate employees unable to speak to the policies and the safe storage of hazardous chemicals.
- Continue audits until specific interventions identified, and policies and procedures are operationalized to prevent the same actions or practices from occurring in the future.
- Address any concerns or questions regarding hazardous chemicals immediately.
- Verify completion of education on policies related to chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured by all staff.
- Conduct audits of the facility to ensure all hazardous chemicals are properly stored, supply room doors and cabinets are locked, housekeeping carts are locked when not in use.
- Conduct audits on doors where hazardous materials are kept.
- Secure or repair any door found to be unsecured or in need of repair. Enter work orders for any door found unsecured and in need of repair in the electronic work order system for tracking and reporting.
- Provide audit results to the Administrator.
- Review audits in Quality Assurance (QA) and monitor in the QAPI meeting until deemed compliant.