Failure to Prevent Resident Skin Irritation from Laundry Detergent
Penalty
Summary
The facility failed to ensure that residents were protected from skin irritation and rashes associated with the use of a specific laundry detergent known to cause such reactions. During the survey, it was found that the blue detergent, which had previously caused outbreaks of rashes and itchiness among approximately half of the residents (from neck to feet, but not on hands or face), was still being stored and used in the facility. Record review and staff interviews confirmed that the hypoallergenic detergent was intended for use, but when it was unavailable, staff substituted the blue detergent, despite being aware of its adverse effects on residents. Observation in the laundry area revealed both the blue and a clear detergent present, with the blue detergent still accessible and connected for use. The laundry aide confirmed that the blue detergent was used as a backup and acknowledged that its use led to skin issues among residents. The administrator was unaware that the blue detergent remained in use, despite previous complaints and known skin-related concerns. This sequence of actions and inactions resulted in a substantiated deficiency affecting all residents reviewed during the survey.