F0689

J

Failure to Prevent Resident Access to Antifreeze Resulting in Ethylene Glycol Ingestion

Bridgeville, Pennsylvania Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from access to harmful chemicals, resulting in the ingestion of ethylene glycol (antifreeze) and subsequent hospitalization. Facility policy on accidents and incidents required reporting, review, and investigation of all accidents/incidents, including determining root causes and contributing factors and identifying measures to reduce further occurrences and adverse outcomes. Despite this policy, a resident with a known history of self-harm behavior and psychiatric issues was able to obtain and keep a gallon of Peak 50/50 Prediluted Antifreeze in their room without detection by staff.

The resident, who was cognitively intact with a BIMS score of 15, had diagnoses including toxic effects of glycols, Parkinson’s disease, and depression. Medical documentation showed prior attempts or suspected attempts at self-harm, including a recent hospitalization for Seroquel overdose and a voluntary psychiatric admission. Hospital records further documented that the resident had been hospitalized for acute kidney injury and metabolic acidosis due to ethylene glycol ingestion, with progress notes indicating suspected self-harm with ethylene glycol requiring ICU care, intubation, and temporary dialysis. The resident also had a history of cocaine use and overuse of Seroquel, and the care plan identified potential risk for ideations of self-harm related to PTSD, glycol toxicity, and hallucinations.

Following another episode of altered mental status, the resident was transferred to the emergency room, and the hospital later contacted the facility with concerns that the resident had ingested antifreeze and requested a search of the resident’s room. Staff then found a gallon jug of Peak 50/50 Prediluted Antifreeze in the resident’s closed cupboard inside a yellow dollar store bag, without a receipt. The LPN who located the jug reported that the cap still had a plastic seal around the lid, but he was able to twist the lid off without breaking the plastic seal. Staff interviews indicated that the resident frequently used third-party delivery services such as DoorDash, and that the resident was generally quiet, stayed to herself, did not use the call bell, and kept her door or privacy curtain closed. The RN Unit Manager stated he was not aware of the resident’s history of self-harm. These circumstances show that the resident was able to obtain and store a toxic chemical in her room, despite her documented psychiatric history and prior glycol toxicity, and without staff awareness or intervention, leading to ingestion of ethylene glycol and hospitalization.

The survey identified this failure to ensure protection from accident hazards and to provide adequate supervision as having resulted in actual harm to one resident and constituting an Immediate Jeopardy situation. The deficiency was cited under multiple state regulatory provisions related to licensee responsibility, management, clinical records, resident care planning, and nursing services.

Removal Plan

• Complete an initial audit to identify any resident with a diagnosis of self-harm attempt or ideation and update care plans with interventions.
• DON or designee will educate staff on the accidents policy (OPS100).
• Establish a protocol related to DoorDash and other deliveries; share it at the AD HOC resident council, communicate to families via Regroup, and educate staff.
• DON or designee will complete an audit to verify residents with self-harm attempts and/or ideation are placed on psych services, have a care plan initiated, and have interventions added to the Kardex.
• Report audit results to the QAPI Committee.