Failure to Prevent Ingestion of Hazardous Items by Resident with PICA
Penalty
Summary
The facility failed to consistently implement interventions to prevent a resident with profound intellectual disability and PICA from ingesting non-food items, specifically an exam glove. The resident's care plan indicated a need for 1:1 staff supervision at all times to prevent ingestion of unsafe items, as the resident was known to be very sly and able to obtain items that were not digestible. Despite this, observations and interviews revealed that nitrile exam gloves were stored in an easily accessible drawer in the resident's bathroom and that a small trash can containing used gloves and paper towels was within reach in the resident's room. Staff confirmed that the resident had good hand dexterity, could move quickly, and would attempt to grab items within their vicinity. On one occasion, a nursing assistant discovered an intact nitrile exam glove in the resident's ileostomy stool pouch, indicating that the resident had ingested the glove. Further review of the facility's investigation and staff interviews confirmed that no changes had been made to the storage of gloves or the trash can following the incident. The staff responsible for 1:1 supervision stated that they were required to remain within arm's reach and maintain constant eyesight of the resident, acknowledging the resident's ability to quickly access and ingest items. The facility was unable to determine exactly how or when the ingestion occurred, but the presence of accessible gloves and inadequate environmental controls contributed to the deficiency.