Resident Accessed Bleach Solution Due to Inadequate Hazard Control
Penalty
Summary
A deficiency occurred when a resident with diagnoses including anxiety disorder, unspecified dementia, schizophrenia, and cognitive communication deficit was able to access and potentially ingest a cup containing a bleach and soap solution. The resident, who was dependent in several activities of daily living and had impaired decision-making abilities, was observed by kitchen staff with a cup that had been used to soak dishes in a diluted bleach solution. The staff member immediately intervened and notified nursing staff. The resident was assessed, found to be alert and oriented, and was subsequently sent to the emergency room for evaluation, where no toxic substances were detected and all laboratory results were normal. Interviews with staff revealed that the cup containing the bleach solution was left accessible on a cart in the kitchen doorway, allowing the resident to obtain it. The facility's policy on safety and supervision was reviewed, which emphasizes both a facility-oriented and individualized approach to resident safety. The incident demonstrated a failure to ensure that hazardous cleaning solutions were not accessible to residents, particularly those with cognitive impairments and a history of impaired decision-making.