**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of facility documentation, clinical records, Safety Data Sheet, facility policies, observations, and interview with staff, it was determined that the facility failed to secure the housekeeping cart and hazardous chemical products and failed to ensure that these products were not accessible to residents in one of eight nursing units. ([NAME] 1 nursing unit). These failures resulted in Resident R1 able to access and drank hazardous chemical product and experienced episodes of emesis. This failure resulted in an Immediate Jeopardy situation for Resident R1 and other residents at risk for serious harm in the [NAME] 1 nursing unit. Findings include: Review of the facility document title Housekeeping Cart Safety undated revealed: 1. Housekeeping carts are never to be left unattended (if you have to leave your cart, it must be placed in the locked housekeeping closet). 2. Housekeeping carts are to be locked at all times. 3. Chemicals are never to be left unattended. 4. Housekeeping carts and Closets are to be checked daily to make sure all equipment is functional. 5. When chemicals aren't being used they must be stored inside the housekeeping cart and it must be locked. 6. All chemicals must be in a properly labeled bottle. Review of facility policy Housekeeping Operational Manual date March 2016, revealed, Chemical and Cleaning Agents: Safety in a healthcare environment is not only limited to accidents and injuries. To provide a safe and hazard free environment all employees must also utilize cleaning chemicals properly and in observance of all safety precautions. All housekeeping employees will be using cleaning chemicals on a regular basis and, to ensure optimum levels of safety, should follow some simple guidelines. Never handle any chemical or cleaning agent without wearing proper personal when protective equipment (always wear gloves, wear goggles and gowns instructed). Follow dilution ratios and mixing instruction exactly according to product specifications. All chemicals and cleaning agents must be stored in labeled containers. Store all chemicals and cleaning agents in designated locked storage areas. Never leave any chemicals or cleaning agents unattended, even for even for a moment. Never allow residents, visitors or untrained employees to handle any chemicals or cleaning agents. Never spray any chemicals or cleaning agents in the presence of residents or visitors. Never spray any chemicals or cleaning agents in the presence of food or beverages. Never mix chemicals or cleaning agents for any reason. Never used. chemicals or cleaning agents in any manner other than that for which they were intended Never consume any chemicals or cleaning agents. Review of Hazard Determination System (HDS) (A system used to rate chemicals and products based on hazard risk level) revealed that a health rating of 0 - minimum hazard 1 - Can cause irritation if not treated 2 - Can cause injury. Requires prompt treatment 3 - Can cause serious injury despite medical treatment 4 - Can cause death or major injury despite medical treatment. Review of SDS (a document that contains detailed information about the safety and health impacting aspects of various substances and products.), sheet for chemical product [NAME] revealed that the product use was Neutral Disinfectant Cleaner This product was a registered pesticide. GHS Label Element: Classified as Corrosive which indicated that the chemical damages metal and living tissues on contact. Skin corrosion and serious eye damages. Signal Word: Danger Hazard Statement: May be corrosive to eyes. Cause skin burns, May be harmful if swallowed. Precautionary Statements: Wear protective gloves, splash goggles, face shield and protective clothing. Wash thoroughly after handling. Acute Effects: Eyes: May cause irreversible damage Skin: Causes skin burns, Inhalation: Mists and vapors may be irritating to throat and respiratory tract. Ingestion: Harmful if swallowed. First Aid Measures: Ingestion: Do not induce vomiting, Drink copious amounts of water. Seek medical attention immediately. Hazardous Determination System (HDS): score: Health: 3. (Can cause serious injury despite medical treatment) Review of SDS sheet for chemical product Fusion Pink revealed that the product use was Air freshener/deodorizer GHS Label Element: Classified as Harmful Irritant which indicated that the chemical can cause skin irritation and acute toxicity. Signal Word: Warning Hazard Statement: May cause skin. Precautionary Statements: Wear protective gloves and eye protection. Wash thoroughly after handling. Acute Effects: Ingestion: Maybe irritating to the mouth, throat and gastrointestinal systems. Hazardous Determination System (HDS): score: Health: 1 Review of SDS sheet for chemical product Fusion Plum revealed that the product use was Disinfectant Cleaner This product was a registered pesticide. GHS Label Element: Classified as Corrosive which indicated that the chemical damages metal and living tissues on contact. Skin corrosion and serious eye damages. Signal Word: Danger Hazard Statement: Cause eye and skin burns, Causes respiratory tract irritation. May be harmful if swallowed. Precautionary Statements: Wear protective gloves, splash goggles, face shield and protective clothing. Wash thoroughly after handling. Acute Effects: Eyes: Causes burns, inflammation of the eye Skin: Corrosive to skin Ingestion: Harmful if swallowed. May cause burns to mouth throat and stomach. Ingestion may cause erosion of mucous membranes and perforation of the esophagus of stomach. First Aid Measures: Ingestion: Do not induce vomiting, Drink copious amounts of water. Seek medical attention immediately. Hazardous Determination System (HDS): score: Health: 3. (Can cause serious injury despite medical treatment). Review of clinical record for Resident R1 revealed that the resident was admitted to the facility on [DATE], with diagnosis including, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) and Wernicke's encephalopathy (a type of brain injury that mostly happens to people who drink a lot of alcohol). Review of Minimum Data Set MDS- (assessment of resident care needs) for Resident R1 dated December 3, 2022, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 5 which indicated that the resident's cognitive status was severely impaired. Review of care plan for Resident R1 dated March 7, 2017, revealed that Resident R1 had a history of suicidal ideation with intervention to remove all dangerous objects from resident's environment. Review of facility documentation dated March 1, 2023, revealed that the unit had a flood, housekeeping staff left the housekeeping cart by the nurse's station so that the nurses could disinfect appropriately. The cart has a closed locked compartment that contained disinfectant. Resident R1 was observed at 7:30 a.m. with a bottle of disinfectant in her hand close to her mouth. A nursing assistant called the name of resident, ran to her and took the bottle from her. Resident was examined by her physician approximately at 9:30 a.m. with stable vital signs no abnormality. Resident was ambulating on the unit without any adverse effect. At 10:51 a.m. had her weight taken, offered water which she drank with no nausea or vomiting or complaint. At 12 noon she had normal bowel movement, vital signs stable and ambulating in hallway and later sat in the chair in the hallway. At 12:55, nurse went to check on resident for observation and did not see her in her room. She was observed in another room lying in bed unresponsive, Cardio Pulmonary Resuscitation (CPR) was initiated, 9-1-1 was called for EMS (Emergency Medical Services). EMS continued CPR. The resident was pronounced dead at 1:21 p.m. Review of progress note dated March 1, 2023, revealed that the nurse was called to the floor, he notified that the resident was seen by staff with bottle of [NAME] disinfectant in her hands, staff removed bottle from resident. Vital signs stable, no distress noted, no irritation of mouth face or hands, nurse stayed with resident. Nurse called the position control center. Gave name of cleaner and all information form SDS sheet along with label ingredients answered all questions from poison control center. Poison control center said the PH level is between 6-8 means, non-caustic and ingredients listed are not poisonous no need for medical intervention. Milk given, resident alert and verbal. Physician assessed resident no new orders. Resident was monitored by staff. Review of progress note dated March 1, 2023, at 12:55 p.m. revealed that the resident was found in another resident's room lying on her back flat and unresponsive. No pulse noted and unable to obtain vital signs. CPR-(Cardiopulmonary resuscitation) initiated and 911 called. Review of physician progress note dated March 1, 2023, at 4:31 p.m. revealed that the resident expired. The physician spoke with coroner and agreed on the cause of death as Wernicke's encephalopathy and dementia. Review of facility documentation revealed that an autopsy (a postmortem examination to discover the cause of death or the extent of disease.) was not performed based on physician's discussion with the coroner. Interview with Nursing Assistant, Employee E4, on March 7, 2023, at 10:20 a.m. stated around 7.45 a.m. on March 1, 2023, she was taking another resident to breakfast, when she saw Resident R1 drinking the cleaning liquid [NAME] in front of the house keeping cart, which was placed in front of the janitor closet. Employee E4 stated she saw resident lift the open bottle to her mouth and drinking it. Employee E4 further stated that she ran towards her calling her name loudly and snatched it from her there was over half of the solution was left in the container, but it was not full. Employee E4 stated she saw another cleaning product similar shape of [NAME] bottle stored unsecured on top of the house keeping cart. She opened the janitor closet which was unlocked at that time and secured cart in the janitor closet. Employee E4 also stated she saw Resident R1 vomit large amount of clear vomitus on top of the breakfast cart around 8:30 a.m. Employee stated nurse was aware of the vomiting. Interview with Nursing Assistant, Employee E5, on March 7, 2023, at 10:39 a.m. stated she was behind Employee E4 when Resident R1 drank the disinfectant liquid. She saw Resident R1 vomit right after she drank the milk. Resident R1 vomited again on top of the breakfast cart around 8:30 a.m. and vomited for the third time at around 10:00 a.m. Employee E5 stated she noticed a change in Resident R1's voice it was like hoarseness. Employee E4 also stated Resident R1 did not eat her breakfast, only drank few sips of liquid and her lunch tray was untouched. Interview with Employee E6, Licensed Nurse, on March 7, 2023, at 10:29 a.m. stated after Resident R1 drank the liquid the resident's vital signs were taken and they were normal. Later in the shift Resident R1 was found unresponsive in another resident's bed. Interview with the Physician, Employee E11, on March 11, 2023, at 1:13 p.m. stated staff showed him a bottle from where the resident was drinking chemical disinfectant. He did not think she drank much from that bottle. However, physician stated he did not know if resident drank any liquid prior to that. He stated that the resident was stable when he assessed her around 9:00 a.m. He verbally ordered the nurse to closely monitor resident by checking vital signs and assessment every 15 to 30 minutes. Interview with Nursing Assistant, Employee E7, on March 7, 2023, at 10:46 a.m. stated she saw the janitor room was little open and the cart was in the hallway next to the door. Employee E7 stated she did not close the door because she thought there was someone in the janitor closet room. Interview with Housekeeping staff, Employee E9, on March 7, 2023, at 10:12 a.m. stated she worked on March 1, 2023, but her shift did not start until 9.00 a.m. She stated the employee from previous day left the cart in the hallway. She stated staff was supposed to lock the cart and store it inside locked janitor closet at the end of their shift. Observation of Employee E8's housekeeping cart located on [NAME] 2 nursing unit revealed that the storage compartment contained two bottle of [NAME] multi surface cleaner disinfectant, one bottle of pink fusion, one bottle of pure bright germicidal ultra-bleach liquid, one full bottle of unlabeled bottle. Employee E8 stated it was bleach. Interview with Housekeeping Staff, Employee E8, on March 7, 2023, at 9.58 a.m. stated staff was supposed to store housekeeping carts locked inside the janitor closet room on each floor. Observation of Employee E8's housekeeping cart located on [NAME] 1 nursing unit revealed that the storage compartment contained one bottle of [NAME] multi surface cleaner disinfectant, one bottle of soap liquid, one bottle of pure bright germicidal ultra-bleach liquid, one full bottle of unlabeled bottle. Employee E8 stated it was bleach. Observation of the [NAME] 1 nursing unit on March 7, 2023, at 10:01 a.m. revealed Employee E8 opening janitors closet without a key. Observation of the [NAME] 1 nursing unit on March 7, 2023, at 10:06 a.m. revealed that the janitor's closet was unlocked, and the surveyor was able to open it without a key. One bottle of hand sanitizer solution was observed store in the unlocked housekeeping closet. Continued observations revealed that Housekeeping Staff, Employee E8 closed the janitor's closet. It was also observed that [NAME] 1's janitor closet door was not equipped with auto lock, which required to be locked every time it was opened. Interview with Housekeeping Director, Employee E10, on March 7, 2023, at 12:00 a.m. stated on March 1, 2023, he observed the housekeeping cart, where Resident R1 drank the [NAME] cleaning solution, had a broken door and it was not closing properly. Employee E10 stated he completed an audit and found another cart with a broken door. Employee E10 stated nurses on the floor had keys to the janitor closet and the carts did not need to stay on the hallway. Employee E10 confirmed that prior to Resident R1 was observe drinking [NAME] disinfectant on March 1, 2023, Housekeeping Staff, Employee E11, left the cart in the hallway to clean a flood, which was not needed as the nurses had the keys to the janitor's closet. Employee E10 stated staff should ensure that the cart was locked if unattended. Employee E10 also confirmed that the housekeeping department used harmful chemical and it was a potential hazard to leave it unattended in dementia unit or around residents with dementia. Further review of the facility investigation revealed no evidence that the facility determined the amount of unsecured cleaning supplies available on the housekeeping cart and the amount Resident R1 ingested. It was also revealed that Resident R1 and other residents on the dementia unit had access to the broken housekeeping cart, cleaning chemicals inside the locked compartment of the cart, unsecured cleaning chemicals on top of the cart, and unlocked janitor's closet. Review of facility documentation provided by the facility revealed that on March 1, 2023, there were 5 residents on [NAME] 1 with diagnosis of dementia and 22 residents on [NAME] 2 with diagnosis of dementia, 5 of those residents were ambulatory. Interview with the Nursing Home Administrator on March 7, 2023, at 2:45 confirmed that housekeeping carts and cleaning supplies should not be left unattended, and unsecured housekeeping chemicals on March 1, 2023, created an environment potential to cause serious harm to the residents. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on March 7, 2023, at 4:06 p.m. for the facility's failure to ensure that the resident environment was free of accident hazards, as the facility failed to secure the housekeeping cart and hazardous chemical products and failed to ensure that these products were not accessible to residents in one nursing unit. These failures resulted in Resident R1 able to access and drank hazardous chemical product and experienced episodes of emesis. These failures also placed Resident R1 and other residents in the unit at risk for serious harm including death. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 7, 2022, at 4:10 p.m. The facility submitted a written plan of action on March 7, 2023, at 7.12 p.m. and implemented the plan of action which included: 1. All housekeeping carts were inspected on to ensure that all housekeeping locking mechanism are working properly and chemicals are securely locked on March 1, 2023. No supplies will be on top of the cart. 2. All housekeeping carts removed from the units March 7, 2023, Carts will be stowed in the housekeeping supply room in the basement not accessible to residents. Housekeeping carts when in use and not within housekeeping eyesight the disinfectant compartment will be locked 3. All housekeeping carts inspected March 7, 2023, to ensure locking mechanism are working and locking properly before the carts are taken to the units. If a cart locking mechanism is not locking properly, the cart will be removed from service. Maintenance will be notified to complete repair before the cart is put back in service. Maintenance audited all housekeeping closets to ensure that door locks properly and lock has a self-locking lock on March 7, 2023. 4. All Healthcare center staff will be educated on the following before the beginning of their shift starting on March 7, 2023: -Housekeepers will be educated about checking the locking mechanism of the housekeeping carts compartment for disinfectants before taking carts to the unit to ensure that locking mechanism is working properly. Cart will be removed from service immediately if locking mechanism is not locking properly. Maintenance will complete repair before cart is put back in service. -Housekeeping carts will be removed from the unit at the end of the shift and will be stored in the housekeeping supply room in the basement. -Housekeeping carts when in use and not within eyesight of housekeeper must be locked. -Janitor closets will be locked at all times and the lock must be self-locking lock. -Housekeeping chemical bottles will be labelled. -If a bottle does not have a label housekeeping supervisor will be notified, and bottle will be removed. -supervisor will be notified immediately -Inservice will be completed by end of March 8, 2023. 5. Unit round audit will be completed by NHA or designee daily x 1 week starting March 8, 2023, and then weekly x 4, and then monthly x 3 to ensure housekeeping closet are locked, carts are locked when on the units. Housekeeping director will audit all housekeeping carts for chemical labels to ensure that all chemical are labelled daily x 1 week starting March 8, 2023, then weekly x 4 weeks, then Monthly x 3 months. Results of audits will be submitted to QAPI until substantial compliance is achieved On March 8, 2023, between 1:15 p.m. and at 3:25 p.m. the action plan was reviewed, observation was made of all eight nursing units, janitor's closet and housekeeping carts. All janitor's closets were found to be locked and their locking mechanism working properly. Housekeeping carts were safely stored. Maintenance and safety rounds audits were reviewed. Interviews were conducted with staff to confirm that the in-service education was completed. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on March 8, 2023, at 3:48 p.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa.Code 201.18(b)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies