Unsecured Hazardous Chemicals Accessible to Wandering Residents in Memory Care Unit
Penalty
Summary
The facility failed to ensure that hazardous chemicals were secured and inaccessible to residents who wander, particularly in the memory care unit. Surveyors observed three rooms— a clean linen closet, a soiled linen closet, and a whirlpool/shower room— all found unlocked and containing unsecured hazardous chemicals such as disinfectant cleaner, all-purpose cleaner, degreaser, bleach, hand sanitizer, and personal care items labeled to be kept out of reach of children. Keys to these storage areas were found hanging nearby or missing, and staff interviews confirmed that the doors were supposed to be locked but were not, with one LPN noting that a resident had previously taken the key and that keys could not be located. Staff also reported that the cabinet in the shower room had not been locked for approximately one month. A resident with severe cognitive impairment and a diagnosis of dementia was observed wandering and opening the unlocked clean linen closet containing hazardous chemicals. The administrator acknowledged that there was no formal policy regarding chemical storage and assumed it was understood that doors should be locked. The deficiency was identified for 10 of 26 wandering residents in the memory care unit, with 12 rooms in the facility identified as storing hazardous chemicals.
Removal Plan
- Locks on the clean linen room and dirty room have been locked.
- Padlock on the shower cabinet has been replaced.
- Facility has been checked for chemicals.
- Keys to these rooms will be on a separate key chain locked in the Medication Cart.
- In person and telephone in-services were begun on all employees about chemical storage.
- Monitoring will be conducted.