Failure to Protect a Resident From Chemical Spray Abuse by Housekeeping Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and mental abuse by housekeeping staff. Video evidence from the facility showed the Housekeeping Manager spraying a bottle identified by the Nursing Home Administrator as Clorox bleach cleaner directly at the resident’s face in a sixth-floor hallway, with approximately five sprays observed. During this incident, a housekeeper was seen holding the resident’s wheelchair in place while the Housekeeping Manager sprayed the chemical. A CNA who witnessed the event reported that the Housekeeping Manager stated, "I'm gonna fuck him up" and then sprayed more bleach cleaner into the resident’s face, and the CNA recognized the product as bleach spray by its smell. The resident involved had diagnoses including schizoaffective disorder, dementia, acquired absence of the left leg below the knee, and asthma, and was wheelchair-bound with moderate cognitive impairment. Prior documentation indicated the resident had adequate vision, did not wear corrective lenses, and had no history of eye disease or corneal haze, aside from dry eyes. A practitioner exam earlier in the month documented normal eye findings with white conjunctiva and non-icteric sclera, and the DON confirmed there were no prior eye consultations or documented eye conditions beyond dry eyes. Following the incident, the resident reported that staff sprayed a chemical in his eyes, that his right eye remained painful and "messed up," and that he had been treated at a hospital. Hospital and ophthalmology records documented evaluation for eye pain and chemical exposure of the eyes, with findings of significant epithelial irritation, corneal haze that was improving, mild conjunctival redness, and periorbital puffiness. The ophthalmology consultation diagnosed chemical exposure of the eye with chemical damage to the front of the eyes, noted as improving, and specified there was no limbal ischemia. These findings were directly linked in the medical record to the allegation of chemical exposure during a confrontation between the resident and a facility staff member.
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