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Based on record review and staff interview, the facility failed to ensure a safe environment for one patient with a known history of consuming hand sanitizer (A144). The cumulative effect of this systemic practice resulted in patient harm and a risk to the health and safety of similar patients.

Based on record review and staff interview, the facility failed to ensure a safe environment for one patient with a known history of consuming hand sanitizer, Patient #4. A total of three active patient records were reviewed. The census was 104.

Findings include:

Review of Patient #4's medical record revealed a known history of consuming hand sanitizer, including while at the facility. Patient #4's Hospital Problem List included this alert to staff from 08/09/20, "patient will drink hand sanitizer in hospital. When admitting and treating please be aware."

On 09/09/20 at 7:55 AM a Social Worker (SW) documented a note regarding Patient #4. In the note the SW commented "when patient is discharged he will require a police escort off of the premises due to hx of wandering hospital consuming hand sanitizer."

Patient #4 presented to the ED again on 09/09/20 at 3:54 PM and was discharged at 6:04 PM. Patient #4 returned to the ED on 09/09/20 at 8:29 PM and was discharged at 9:43 PM.

On 09/10/20 at 2:34 AM Patient #4 returned to the ED and this time was admitted to the hospital. The ED provider note revealed Patient #4 was a 42 year old male brought in by ambulance with hematemesis (vomiting of blood). Patient #4 admitted to his last drink was approximately three (3) hours ago.

At 2:51 AM a Triage Note revealed Patient #4 reported drinking mouthwash and hand sanitizer. At 5:10 AM the decision was made to admit Patient #4 for GI (gastrointestinal) bleed. One more provider note was documented at 5:30 AM on 09/10/20. Patient #4 was described as stable with diagnoses of (1) hematemesis with nausea, (2) acute alcoholic intoxication with complication, and (3) history of esophageal varices. The plan was to admit to a telemetry floor.

Report was called to internal medicine at 6:14 AM, and Patient #4 was transferred to the sixth floor. Review of the history & physical by Internal Medicine revealed Patient #4 was alert & oriented, had no neurologic focal deficits, and was not in respiratory distress at that time.

Later that morning, on 09/10/20 at 8:00 AM, facility Protective Services completed an incident report involving Patient #4. Protective Services discovered through review of security video Patient #4 stole a bottle of hand sanitizer from one of the dispensing units in the ED. It reportedly happened during Patient #4's second visit to the ED on the evening of 09/09/20.

On 09/10/20 at 8:38 AM Patient #4 was seen by Gastroenterology. Patient #4 was "awake, alert, oriented, cooperative, and in no acute distress" and vital signs were stable. Assessment included "hematemesis, melena, acute blood loss anemia in patient with ETOH abuse and suspected cirrhosis."

On 09/11/2020 Internal Medicine (IM) rounded on Patient #4 at 11:05 AM. Patient #4 reported he was sick and just threw up. IM observed a large emesis in the bathroom and noted Patient #4 was slurring his words. Staff thought it may be related to a medication he received, but Patient #4 grew increasingly agitated. The nurse practitioner proceeded to search Patient #4's room and discovered a "near empty bottle" of hand sanitizer containing 70% ethanol. A second bottle, empty, was found in the trash can of Patient #4's bathroom. The count ingested was undetermined, but staff noted each bottle holds 1000 ml (milliliters). Patient #4 began yelling and talking about the fighting with staff, so a Code Violet (for violent person) was called. IM determined Patient #4 would be transferred to the ICU (intensive care unit) for treatment of "acute alcohol intoxication due to ingestion of hand sanitizer." from alcohol consumption and possible aspiration". Twenty six minutes later, at 1:31 AM, a rapid response was called for aspiration with concerns for respiratory failure. The Rapid Response Team arrived at Patient #4's room at 11:40 AM. Patient #4 required intubation, and the rapid response concluded at 11:55 AM with Patient #4 being transferred to the ICU.

A nursing note addendum dated 09/11/20 at 11:30 AM revealed the nurse documented she was called to room 617, patient appeared intoxicated. The day prior (9/10/20) all hand sanitizer and alcohol containing products were removed from patient's room. Patient transferred to ICU bed 4.

There was no additional evidence in the nursing notes regarding interventions to ensure the patient could not obtain hand sanitizer from other locations on the nursing floor.

A Critical Care Progress Note dated 09/11/20 with assessment from 12:05 PM, revealed Patient #4 was being treated for "metabolic/toxic encephalopathy secondary to ethanol intoxication with agitation."

As of 09/16/20 Patient #4 remained in the ICU.