F0684

D

Resident Ingests Acetic Acid Due to Unsupervised, Unlabeled Medication Setup

Suttons Bay, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe medication administration and observation of medication consumption, resulting in a resident ingesting acetic acid intended for catheter flushing. A complaint filed with the State Agency alleged that a nurse gave the resident acetic acid in a regular cup without informing him what it was, and he drank it, believing it was his fluid for taking medications. During interviews, an RN explained that another RN who was in training brought the resident’s oral medications along with two identical glasses containing clear liquid—one with water and one with acetic acid—both in the same type of glass. The RN in training then left the resident alone with the medications and both unlabeled glasses, without instructing the resident which glass contained water and without witnessing the medication administration.

The resident reported that the nurse placed two glasses of clear liquid and a cup of medications on his bedside table and left the room without observing him take his medications. While taking his medications, he realized that what he was drinking was not water and then discarded it, later becoming upset about the incident. The resident also stated that the same nurse had previously brought him the wrong medications and that he did not trust her. Additional interviews revealed that the acetic acid was not drawn up in a sterile manner, contrary to the expected use of a syringe or sterile collection cup, and that the orienting RN had only explained the catheter flush procedure verbally and had not witnessed the trainee RN perform an indwelling catheter flush. Review of the trainee RN’s competencies showed no documented check-off for flushing urinary catheters, and the RN was noted to be on an extended orientation process at the time of the incident.