F0689

J

Repeated Hand Sanitizer Ingestion Due to Inadequate Hazard Control and Supervision

Philadelphia, Pennsylvania Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure an environment free of accident hazards and to provide adequate supervision for a resident with known alcohol abuse and cognitive impairment, resulting in repeated ingestion of alcohol-based hand sanitizer. The facility’s Accident & Injury Prevention and Response Policy stated that residents were to be protected from avoidable accidents and injuries through proactive assessment, environmental safety, staff training, and timely response. The Safety Data Sheet for the ProCure Alcohol Gel Hand Sanitizer 70% identified the product as containing 70–75% ethyl alcohol and directed that a physician or poison control center be contacted immediately if ingested. Despite this information, the resident, who had a BIMS score of 10 indicating moderately impaired cognition and documented diagnoses including alcohol abuse, bipolar disorder, COPD, heart failure, and dementia, was able to obtain and ingest hand sanitizer on multiple occasions.

The resident’s history included prior discharge from another LTC facility for alcohol abuse, insurance issues, and behavioral issues, and psychologist notes over several months documented alcohol and cocaine abuse, as well as the resident’s statements that they currently drink, do not plan to stop, and had drunk at a previous nursing home. On one date in January, a nurse observed the resident drinking hand sanitizer during rounds, removed the substance, completed an assessment, and documented stable vital signs. However, the clinical record did not show that the physician was notified of this ingestion or that any interventions were implemented to monitor or supervise the resident specifically related to hand sanitizer consumption. This lack of notification and absence of documented follow-up interventions occurred despite the known hazardous nature of the product and the resident’s substance use history.

In late February, the unit manager documented finding the resident drinking a cup of hand sanitizer, discarding the cup, educating the resident on the dangers of ingestion, and notifying the physician and responsible party. A care plan was then documented indicating that the resident drinks hand sanitizer, with interventions focused on administering medications, analyzing triggers, assessing coping skills and support systems, providing re-education, and encouraging the resident to discuss feelings. Nevertheless, on a subsequent date in March, a nurse again observed the resident in their room with a bottle of hand sanitizer and a cup containing hand sanitizer, and both items were removed. A psychologist note also recorded that the resident was observed drinking hand sanitizer from a cup, with no further documentation of additional interventions to prevent recurrence. Staff interviews confirmed that the resident walked throughout the building unrestricted, could obtain more sanitizer without staff knowledge, and that the unit manager did not ask where the resident had obtained the sanitizer. The DON and NHA acknowledged that the resident drank or was observed with hand sanitizer in a cup on three separate occasions, had a history of alcohol abuse, and continued to have access to hand sanitizer in the facility, leading surveyors to identify an Immediate Jeopardy situation related to hazardous substance access and inadequate supervision.