Failure to Prevent Cognitively Impaired Resident’s Access to Alcohol-Based Hand Sanitizer
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and control of accident hazards when a severely cognitively impaired resident obtained access to an alcohol-based hand rub. The resident was an adult male with multiple diagnoses including alcohol dependence with alcohol-induced mood disorder, alcohol dependence with unspecified alcohol-induced disorder, and alcoholic cirrhosis of the liver. His admission MDS showed a BIMS score of 4, indicating severe cognitive impairment, and he required partial/moderate assistance with ADLs. His care plan addressed mood problems related to alcohol dependence, including monitoring for self-harm, impaired judgment, and safety awareness, but did not document any history of consuming items he was not supposed to. On the date of the incident, an RN documented that the resident was found stacking furniture at his bedroom door, with an open bottle of hand sanitizer on his bedside table. The RN recorded that the resident stated, “Yes I'm F***** up,” and when asked where he obtained the hand sanitizer, the resident responded evasively. The facility’s provider investigation report stated that the administrator was notified that a bottle of hand sanitizer had been found in the resident’s room on the secured unit, that the bottle had been opened, and that the resident had vocalized to the nurse that he had ingested hand sanitizer and other items not located in his room. The report also noted that during subsequent monitoring there was never any indication that emergent services were warranted nor any confirmed indication that the resident consumed the hand sanitizer. Interviews with the DON and Administrator indicated that RN A had reported seeing a small bottle of hand sanitizer on the resident’s bedside table and that the resident had verbalized drinking multiple substances that were not kept within the facility. They stated that the resident should not have had access to the hand sanitizer as it was potentially a chemical hazard and that the hand sanitizer may have been retrieved from a drawer within the nurse’s station. At the time of the surveyor’s observation of the memory unit, all mobile hand sanitizers were locked within the nurse’s medication carts, and no hand sanitizer was observed in the resident’s room. The facility’s general housekeeping policy stated that potentially hazardous substances are to be kept in a safe place accessible only to employees, but the resident’s access to a non-fixed bottle of hand sanitizer in his room demonstrated a failure to prevent access to this potentially hazardous substance.
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