Failure of NHA and DON to Prevent Resident Self-Harm with Toxic Chemical
Penalty
Summary
The deficiency involves the NHA and DON failing to protect a resident with a history of self-harm from accessing harmful chemicals, resulting in an attempted self-harm incident. The facility job descriptions for the NHA and DON state that they are responsible for administering, directing, and coordinating all activities to ensure the highest quality of care, and for providing leadership and oversight of clinical care, nursing practice, and continuous improvement of nursing services. Despite these defined responsibilities, the NHA and DON did not ensure that federal and state guidelines and regulations were followed to prevent resident self-harm. Surveyors determined that this failure allowed a resident with a known history of self-harm to obtain and possess ethylene glycol, a chemical found in antifreeze. The resident ingested the ethylene glycol and required hospital admission. The incident created an Immediate Jeopardy situation for one of two residents reviewed (Resident R1). During an interview, the NHA and DON acknowledged that they failed to effectively manage the facility to protect residents from self-harm, confirming the identified deficiency under the cited Pennsylvania regulatory codes.
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