F0689

J

Unsecured Water Beads on Dementia Unit Lead to Resident Ingestion and ICU Transfer

Ebensburg, Pennsylvania Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involved the facility’s failure to keep water-absorbing beads, an identified choking and obstruction hazard, securely stored on a dementia unit where residents wander. Facility policy required that items needing close supervision be stored in locked cabinets or other secure areas, with cabinets locked when not in active use. Manufacturer instructions and a U.S. Consumer Product Safety Division warning specified that water beads can expand significantly when ingested and pose a serious medical emergency, including life-threatening intestinal blockages or choking. Despite these known hazards and policies, the water beads used for activities were kept in a cabinet in the north lounge activity/dining room on the dementia unit and were not secured.

Resident 1, who had dementia, cognitive impairment, dysphagia, and a care plan indicating wandering behavior and the need for a secure environment, was independently mobile on the unit. On the night of the incident, a nurse aide observed the resident in bed at approximately 2:15 a.m. with nothing unusual noted. During 5:00 a.m. rounds, two nurse aides entered the resident’s room and found the resident in bed with the floor covered in water beads. The resident was coughing and spitting water beads out of his mouth. One aide went to get the LPN, and neither aide reported seeing the resident access any items.

At about the same time, one of the nurse aides noticed that the north lounge activity room door was open, the light was on, and the cabinet where the water beads were kept was open. When the LPN arrived to assess the resident, she observed the resident coughing up water beads and mucus, with stable vital signs but bilateral rattling lung sounds, and notified the RN. The RN’s assessment documented that the resident was awake, alert with confusion, spitting up water beads, with even, unlabored respirations, cough, and diminished lung sounds with congestion. The DON later confirmed that the water beads had been unsecured in the north lounge activity/dining room on the dementia unit and that it was unknown how many beads the resident had ingested. The resident was transferred to the hospital and admitted to the intensive care unit.

Removal Plan

• Removed the water beads from the facility.
• Identified residents that have the potential to be affected.
• Completed a house review of rooms and lounges for any foreign objects and any other items that would pose a similar issue.
• Provided education to nursing and activities staff on removing items that would pose a potential risk for residents to ingest.
• Locked and secured all activity cabinets.
• Educated newly hired staff on removing items that would pose a potential risk for residents to ingest.
• Will monitor and maintain ongoing compliance.
• Director of Nursing or designee will complete observation audits to ensure items that have potential to be ingested are removed and activity cabinets are locked.