Facility I.D. Number: 0040808
1501 Shoemaker Dr.
Murphysboro, IL 62966
On 12-18-98 the facility notified the Department of Public Health that R-1 had been admitted to the hospital on 12-12-98 due to ingestion of a chemical substance, Lemon Quat, which is a liquid disinfectant. Per the incident report filed by the facility R-1 was found in his bedroom at 6:45 p.m.on 12-12-98 with an open and empty bottle of the disinfectant. R-1 was transferred to the emergency room and admitted to the hospital with a diagnosis of chemical ingestion for 23 hour observation. Per facility documentation, R-1 had several emesis while he was in the emergency room that consisted of Lemon Quat (staff recognized it by the smell), several small pieces of soap, and a paper napkin. R-1 was released from the hospital on 12-13-98 and returned to the facility.
On 1-15-98 the Incident Report Investigation was initiated. The facility was entered at 9 a.m. After a brief conversation with E-3 to establish the purpose of the visit, a tour of the facility was done. At 9:20 a.m. a housekeeping cart was observed parked across from the kitchen, in front of B-wing. There were no staff present with the cart. A door in the lower portion of the cart was observed to be ajar and on inspection, a plastic spray bottle of "Blue" cleaner was present. The label on the cleaner stated "caution, keep out of the reach of children" The lower portion of the cart had a lock present, but was not locked. Interview of E-1 revealed that the lock was broken. E-1 stated in response to my question "Yes, we are supposed to keep it locked in the bottom of the cart but the lock is broken, so we can't lock it up". E-1 was also asked if the "Blue" cleaner was always on her cart, and she replied "Yes".
At 9:25 a.m. another housekeeping cart was observed on D-wing. The cart was parked down the hallway past the nurses station. There were no staff in sight of the cart. The cart was inspected and found to be unlocked. A tall plastic spray bottle with a liquid substance was observed in the lower portion of the cart.
The bottle did not have a label on it to identify the content. E-2 was interviewed as to the possible contents of the bottle and he opened the bottle, smelled the contents, and said "it's lemon quat" E-2 was then asked if the lemon quat should be kept locked out of clients reach. E-2 replied, "Oh yes, it's poison!" E-2 also verified that the cart was not locked, and could not be locked, because it was broken.
From 9 a.m. to 9:30 a.m. there were clients in the facility who had not left for day training, including several that were fully ambulatory. There was potential that any of those ambulatory clients could have had access to the liquids on either of the cleaning carts.
R-1 has a behavior program in place to address his long standing diagnosis of PICA. The program identifies the consequences of the behavior as potentially life-threatening to him due to the risk of choking and the possibility of eating something hazardous to his health. Current interventions are to verbally prompt R-1 combined with counseling on the consequences of this behavior. The program also identifies that the PICA behavior varies from high frequency to low frequency, with no known antecedent. The program does not identify what type of staff supervision is required to prevent the behavior. After R-1 was released from the hospital with a diagnosis of chemical ingestion, there were no changes made to the behavior program to prevent R-1 from causing harm to himself again. Record and incident report review verifies that on 12-17-98 R-1 was observed "picking something up off the ground and putting it in his mouth". Staff was not able to see the object, and it was assumed R-1 swallowed whatever it was. On 12-25-98 R-1 ingested 25cc of liquid body soap, and "about 5 inches of tissue paper". On 12-31-98 he swallowed a quarter, and on 1-07-99 he ate a portion of a sponge nerf ball.
Per record verification and staff interview the facility failed to review and update R-1's behavior program for PICA behaviors after he required hospitalization due to the behavior and failed to institute any interventions to prevent R-1 from causing more harm to himself. The facility also failed to monitor the storage of biologicals that could cause illness or even death if ingested. A serious and immediate threat was called on 1-15-99, using core statement III, sub-set two. Failure to maintain equipment and supplies at an acceptable level to ensure health and safety. The facility was notified at 1:35 p.m. of the action.
The serious and immediate threat was removed on 1-15-99 after the facility presented a plan to 1) Prevent future harm from occurring to R-1 by providing constant 1:1 supervision. 2) Prevent access to any chemical substance by the purchase of new locking cleaning carts. 3) Development of a specialized job outline for staff to follow for R-1's PICA behavior.