**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of a facility INCIDENT INVESTIGATION FORM, and review of a facility investigative summary, the facility failed to ensure the residents' environment remained free of accident hazards by failing to ensure staff's personal medication was stored in a secure location that was not accessible to residents. Specifically, on [DATE], Resident Identifier (RI) #1, who had a diagnosis of Dementia with Behaviors, accessed and ingested an unspecified amount of Acetaminophen (a pain reliever/fever reducer also known as Tylenol) from a bottle belonging to Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA). RI #1 was able to obtain the medication because EI #5 placed her purse, which contained the medication, on a table in the 100 hall lobby and left it unsupervised. Subsequently, RI #1 was transferred to the local Emergency Department (ED) on [DATE] for possible overdose of Acetaminophen. This deficient practice placed RI #1, one of seven residents with wandering behaviors, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On [DATE] at 6:35 PM, EI #2, Administrator, was provided a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F689-Free of Accidents Hazards/Supervision/Devices. The immediate jeopardy began on [DATE] and continued until [DATE] when the facility implemented corrective actions to address the identified deficient practice, including ongoing monitoring; thus, immediate jeopardy past noncompliance was cited. Findings Include: On [DATE] at 2:56 PM, the facility submitted an initial report to the State Survey Agency via the Alabama Department of Public Health Online Incident Reporting System. This report indicated RI #1 took Tylenol from an employee's purse, ingested them, and was sent to the ED for further evaluation. RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Dementia with Behavioral Disturbances. A review of RI #1's Significant Change in Status Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] indicated RI #1 had both short and long term memory impairment and moderately impaired cognitive skills for daily decision making. A list provided by the facility, dated [DATE], identified RI #1 as a wandering resident. A facility INCIDENT INVESTIGATION FORM, completed [DATE] by EI #6, Licensed Practical Nurse (LPN), documented: .CNA informs writer she found resident on Hall 100 in dining room (with) pills in hand eating them Resident had gotten into another CNA's purse, obtained a bottle of 500mg (milligram) Tylenol (and) had ingested an unknown amount of the medication. The CNA whom the Tylenol belonged to stated there was 25 pills in the bottle . (resident) took between 3-5 (three to five) Extra Strength Tylenol. Nurse assessed resident. (Up) in w/c (wheelchair) @ (at) table. Mental status checked noted @ baseline .(resident) unable to say what happened. Baseline confusion . A review of the facility's investigative summary, dated [DATE], indicated: .At approximately 7:35 p.m. on Sunday, [DATE], [NAME] CNA (EI #7) observed (RI #1) holding Tylenol tablets taken from the purse of CNA (EI #5). (RI #1) could not state if (he/she) had taken any of the Tylenol and, if so, how many. Staff thus sent (RI #1) to the Emergency Room. Staff also notified Alabama Poison Control. Alabama Poison Control informed staff that given (RI #1's) weight, (he/she) would have had to take at least fifteen tablets of Tylenol to be toxic. RI #1's hospital HISTORY/PHYSICAL EXAMINATION, dated [DATE], documented: .History of Present Illness . patient (RI #1) somehow acquired the purse of . (a facility staff member) and took some pills earlier today. The nurse suspects that it was Tylenol and estimates that patient took about 4-5 500mg tablets. Given concern for overdose, patient brought via EMS (Emergency Medical Services) to ED. In ED, patient initially awake and alert at normal baseline mentation. A few hours after arrival, patient reportedly somnolent prompting RN (Registered Nurse) to sternal rub . Patient woke to sternal rub but was noted to be excessively lethargic . RI #1's hospital DISCHARGE SUMMARY, dated [DATE], documented a final diagnosis of Accidental Drug Overdose, suspected Acetaminophen. A written statement made by EI #7, CNA, dated [DATE], that was included in the facility's investigation, documented: . (EI #7) went to Dining Room on hall 100. (EI #7) turned on lights and (RI #1) was at the . (table) with a pill on . (table) and tablets in hands. According to EI #7's statement, EI #7 informed the nurse and also informed EI #5, since the purse belonged to her. In an interview on [DATE] at 5:39 PM, EI #5, CNA, reported she set her purse down in the 100 hall lobby on the table closest to the hallway. EI #5 stated she did not put her purse in the locker where she had been instructed to put her personal items. EI #5 stated she sat the purse down briefly but got busy and forgot about her purse. EI #5 stated she was in another resident's room when EI #7, CNA, told her RI #1 was in her purse. EI #5 stated she ran down to the 100 hall lobby and saw RI #1 with her purse and the pill bottle in his/her hand. EI #5 identified the medication as Acetaminophen 500mg. EI #5 stated RI #1's mouth was red, the same color as the pills. EI #5 stated she did not see RI #1 put the pills in his/her mouth but the resident's mouth was the same color as the pills. EI #5 stated she counted 25 pills in the bottle prior to coming to work. She stated two pills looked like they had been in the resident's mouth because the outer coating color was off the pills. EI #5 stated she should have put her purse in her locker. EI #5 stated the concern with a resident getting in her purse was the resident could get into something harmful. In a follow-up interview on [DATE] at 1:59 PM, EI #5, CNA, reported she laid her purse on the table in the 100 hall lobby at the beginning of her shift on [DATE]. She stated her purse was left unattended for at least three hours. In an interview on [DATE] at 7:39 AM, EI #6, LPN, reported at about 7:30 PM, EI #7, CNA, told her she found RI #1 at the end of the hallway and the resident had gotten into someone's medication. EI #6 assessed the situation. EI #6 stated EI #5 told her that RI #1 took 500mg Tylenol from her purse that she left at the end of the hall. EI #6 assessed RI #1. EI #6 stated RI #1's mental status was okay, but she was concerned that the resident ingested an unknown amount of Tylenol. EI #6 stated she observed the pill having a red coating, and RI #1's mouth was tinted the same color. EI #6 stated she saw one pill on the floor. EI #6 stated EI #7 stayed with RI #1 while EI #8, RN, assessed the situation. EI #6 stated she started the process for sending the resident to the ED. EI #6 stated staff could use lockers provided by the facility to store personal items. EI #6 stated staff were to never leave items in residents' rooms or anywhere a resident had access. EI #6 stated the medication RI #1 ingested could cause liver failure. In an interview on [DATE] at 3:52 PM, EI #8, RN, reported she was working a different hallway the night RI #1 ingested a staff member's medication. EI #8 stated she found the resident sitting in a wheelchair in the 100 hall dining room (lobby) with EI #5, EI #6 and EI #7. EI #8 stated she observed a red pill on the table that EI #5, CNA, identified as Tylenol. EI #8 stated she observed RI #1 with a red mouth. EI #8 stated EI #5 reported the bottle contained 25 pills but the bottle was labeled as a 100 count bottle. EI #8 stated she instructed EI #7, CNA, to stay with the resident. She instructed EI #5 to get the Tylenol and her belongings and report the incident to EI #9, RN Supervisor. EI #8 said she called Alabama Poison Control, who reported the toxicity level for RI #1 was 15 pills. EI #8 stated the resident could have overdosed, become hypertensive, had liver failure, become unresponsive, become sick or died. In an interview on [DATE] at 4:55 PM, EI #9, RN Supervisor, stated she was working another station when EI #5, CNA, reported to her that RI #1 took Tylenol out of her unattended purse. EI #9 reported EI #5 told her the bottle contained 25 pills when she counted them that morning. EI #9 counted 19 recovered pills. EI #5 told EI #9 that RI #1 spit some of the pills out. They recovered pills from the table that were discolored pink, like the pills had been in someone's mouth. They recovered a total of 21 pills. EI #9 stated she looked up the medication on the internet and confirmed it was Tylenol. In an interview on [DATE] at 4:39 PM, EI #10, CNA, reported she did not see the incident, but she had just checked on RI #1 fifteen to twenty minutes prior to the incident. EI #10 stated RI #1 was in the 100 hall lobby looking at the Christmas tree. EI #10 stated RI #1 had been there most of her shift. When asked if she saw any staff belongings in the 100 hall lobby at that time, EI #10 said she did not see any, but she did not look. In an interview on [DATE] at 9:18 AM, EI #3, Director of Nursing (DON), reported EI #8 called her at home to notify her RI #1 got into EI #5's purse, took Tylenol out, and had possibly ingested three pills. EI #3 instructed her to count the remaining pills and call Poison Control. EI #3 stated the purse should have been in EI #5's locker or vehicle. EI #3 stated staff, including EI #5, were instructed during orientation to use lockers for personal items. EI #3 stated residents could get into something harmful or unsafe if staff left personal items where residents had access. In an interview on [DATE] at 7:07 PM, EI #1, Medical Director, reported RI #1 was found in the act of ingesting Tylenol, but they did not know how many the resident ingested. EI #1 sent the resident to the ED. EI #1 stated 4000mg (eight tablets) of Tylenol would be toxic and could cause liver damage or inflammation. In an interview on [DATE] at 8:11 AM, EI #2, Administrator, reported they did not know why EI #5's purse was available to RI #1, because EI #5 had a locker available for use. EI #2 stated EI #5 assured her that the bottle of Acetaminophen 500mg contained 25 pills, although the bottle was labeled for 100 pills. EI #2 stated the bottle of Tylenol was currently in her possession. During the interview, EI #2 was asked to count the pills remaining in the Tylenol bottle. In the presence of the surveyor, EI #2 counted and confirmed 21 pills remained in the bottle, three of which were lighter pink in color with some of the outer coating gone. EI #2 stated it is unknown how many pills RI #1 ingested. EI #2 stated EI #5 should not have had her purse out, because residents could go through the staff's belongings and get something, such as Tylenol. EI #2 stated the bottle of Tylenol had a warning that severe liver damage could occur if more than 4000mg was taken within a 24 hour period. This deficient practice was cited as a result of the investigation of complaint/report number AL00042551. The facility took immediate action to correct the noncompliance by: 1. Alabama Poison Control notified, and RI #1 sent to the ED on [DATE]. 2. Quality Assurance and Performance Improvement (QAPI) meeting held [DATE] concerning the incident. 3. Education done with EI #5 on [DATE] about not leaving personal items in unsecured areas. 4. Education with all staff about not leaving personal items in unsecured areas initiated [DATE] and completed [DATE]. 5. Rounding sheet for each shift, each hall completed and documented for 10 days ([DATE] to [DATE]) to ensure no staff belongings out in any area of the halls/resident areas. Thereafter, supervisors will round throughout their shifts to ensure staff continue to place their belongings in a secure location. 6. RI #1's care plan was reviewed and updated [DATE] to include approaches to verify potentially hazardous areas are kept locked, to check room for items that pose risk daily and remove if noted and monitor common areas are free from environmental issues and locked areas are maintained secure. After review and verification of the information provided in the facility's corrective action plan, inservice/education records, monitoring tools and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from [DATE] through [DATE] with ongoing monitoring implemented; thus, immediate jeopardy past noncompliance was cited.