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Based on interview, record review, and review of the facility's policies entitled "Patient Rights and Responsibilities," "Supervision of Patients," and "Reporting and Investigating Unusual Incidents," it was determined the facility failed to ensure patient rights were protected and failed to have mechanisms in place to ensure one (1) of ten (10) patients (Patient #1) did not have access to hazardous products. On 06/22/14, staff observed Patient #1 slumped in his/her chair, with seizure-like activity, and the patient had urinated on him/herself. Staff informed the physician of the patient's condition and Patient #1 was transferred to the Emergency Department (ED) of the facility for further evaluation and treatment. Emergency Department staff assessed Patient #1 and, based on laboratory reports, noted the patient's blood alcohol level was "327 CH" (reference range of 0-10). The ED physician intubated the patient, put him/her on mechanical ventilation, and transferred the patient to the Intensive Care Unit (ICU). According to the interviews, the other patients on the unit reported Patient #1 had drunk hand sanitizer that was at the nurses' station. On 06/22/14, at approximately 8:00 PM, facility staff searched Patient #1's room and found three (3) unopened bottles of hand sanitizer, which contained 70 percent alcohol, in Patient #1's room on the psychiatric unit. Interviews with Administrative staff revealed the facility had initially entered the incident as a "Class 1" incident (a simple fact finding report that was documented on the Incident Report Form) and did not conduct an investigation of the incident until 06/25/14, when the facility's Executive Director was made aware of Patient #1's condition.

The failure of the facility to identify and protect patients from neglect and failure to provide a safe environment placed patients at risk for serious injury, harm, impairment, and/or death. Immediate Jeopardy was identified on 06/30/14, was determined to exist on 06/22/14, and is ongoing. The facility was notified of the Immediate Jeopardy on 06/30/14. In addition, it was identified on 06/17/14 during the course of a previous investigation (KY21832) that the Conditions of Participation at 42 CFR 482.13 Patient Rights and 42 CFR 482.23 Nursing Services were not met and the facility was placed on a 23-day termination. Due to the Immediate Jeopardy identified on 06/30/14, the 23-day termination is ongoing.

Refer to A0145.

Based on interview, record review, and review of the facility's policies entitled "Patient Rights and Responsibilities", "Supervision of Patients," and Reporting and Investigating Unusual Incidents", it was determined the facility failed to ensure one (1) of ten (10)sampled patients was protected from neglect. Interviews and review of documentation revealed Patient #1 slumped in his/her chair on the psychiatric unit of the facility on 06/22/14 at approximately 7:00 PM and exhibiting seizure-like activity. Facility staff assessed Patient #1 and transferred the patient to the Emergency Department (ED) of the facility for further evaluation and treatment. On 06/22/14, ED staff assessed Patient #1 and, based on reports that the patient could have ingested hand sanitizer, requested and received "toxicology results" from the laboratory that revealed the patient's blood alcohol level was "327 CH" (with a reference range of 0-10). The ED physician intubated the patient on 06/22/14, placed him/her on mechanical ventilation, and transferred the patient to the Intensive Care Unit (ICU). Continued interviews revealed, based on reports from patients on the psychiatric unit, that Patient #1 had drunk hand sanitizer, staff searched Patient #1's room on 06/22/14, at approximately 8:00 PM, and found three (3) bottles of hand sanitizer. Interviews with patients and nursing staff revealed the hand sanitizer was on the desk at the nursing station on occasion, and within reach of patients.

Based on interviews, the facility initially entered the incident that occurred on 06/22/14 with Patient #1 as a "Class 1" incident (required simple fact finding) and had not conducted an investigation of the incident. However, on 06/25/14, the facility's Executive Director was made aware of Patient #1's elevated alcohol level and that the patient had been placed on mechanical ventilation, and reclassified the incident as a "Level 3" (suspected abuse or neglect, serious injury, or critical in nature or alleges an immediate threat to the health, safety, and welfare of an individual) and initiated an investigation of the incident.

The failure of the facility to identify and protect patients from neglect and failure to provide a safe environment placed patients at risk for serious injury, harm, impairment, and/or death. Immediate Jeopardy was identified on 06/30/14, was determined to exist on 06/22/14, and is ongoing. The facility was notified of the Immediate Jeopardy on 06/30/14. In addition, it was identified on 06/17/14 during the course of a previous investigation (KY21832) that the Conditions of Participation at 42 CFR 482.13 Patient Rights and 42 CFR 482.23 Nursing Services were not met and the facility was placed on 23-day termination. Due to the Immediate Jeopardy identified on 06/30/14, the 23-day termination is ongoing.

The findings include:

Review of the facility's policy titled, "Patient Rights and Responsibilities," dated 02/10/11, revealed patients had the right to be free from verbal or physical abuse, negligence, or harassment while hospitalized.

Review of the facility policy titled, "Supervision of Patients," revised May 2012, revealed patients should be placed on the appropriate level of supervision to assure the safety and well-being of the patient and others. According to the policy, all patients would be monitored every 15 minutes during admission to the psychiatric center.

Review of the facility policy titled, "Reporting and Investigating Unusual Incidents," revised June 2007, revealed it was the responsibility of the facility to have a process in place to report, investigate, and manage incidents related to the protection of the individuals served. In addition, the policy revealed incidents were classified according to the potential for harm to individuals and contained protocols for recording and follow up. Review of the classification of incidents revealed a "Class 1" incident included medication errors, falls with no injury, and were minor in nature and did not create a serious consequence. According to the policy, a "Class 1" incident required simple fact finding to be conducted and documented on the Incident Report Form. The policy revealed a Class 2 incident could include transportation of an individual to the Emergency Department and has the potential to cause serious injury or harm to the health, safety, or welfare of an individual or individuals. Continued review of the policy revealed the facility would be required to complete an Incident Report and retain the Incident Report on file, conduct an inquiry of the incident, and immediately notify the House Coordinator. The policy also revealed if there was reasonable cause present to suspect abuse, neglect, or exploitation after the facility had conducted an initial assessment of the incident or inquiry, the facility was to immediately report the incident to Protection and Permanency, the Department of Management Administrator, and "OIG" (Office of Inspector General); and the incident would be reclassified as "Class 3." Based on the facility's policy, a "Class 3" incident may include suspected abuse or neglect, serious injury, or an event that is critical in nature or alleges an immediate threat to the health, safety, and welfare of an individual or missing individuals.

A review of incident reports provided by the facility for review revealed a report dated 06/22/14 at 7:15 PM that revealed staff observed Patient #1 to have "seizure like" activity and the patient was transferred to the ED. Additional documentation on the incident report by the Unit Manager on 06/23/14 (one day after the incident occurred) revealed staff found the patient with seizure-like activity, sent the patient to the ED for evaluation and treatment, and the patent was admitted to the medical center. Continued review of documentation by Unit Manager #1 revealed the ED physician had reported, "It would take a gallon of hand sanitizer." However, there was no additional information on the report and no additional information to clarify what the physician had referred to in his report.

Continued review of incident reports revealed an incident report dated 06/22/14 at 8:00 PM (45 minutes after the previous incident report), which revealed staff had found three (3) bottles of "intact" hand sanitizer in Patient #1's room. Additional documentation on the incident report by Unit Manager #1 on 06/23/14 (one day after the incident occurred) revealed Patient #1's room had been searched after the patient had been sent to the ED and staff found three (3) bottles of hand sanitizer in the patient's room. Based on the Unit Manager's documentation on the report, staff was informed to keep bottles in their pockets, in the medication room, and out of reach of patients. There was no additional information documented on the report.

Review of the medical record for Patient #1 revealed the facility admitted the patient on 06/18/14 with diagnoses that included Depression, Opiate Abuse, and Possible Seizure. Based on documentation facility staff was to monitor the patient every 15 minutes in accordance with the facility policy. A review of Patient #1's Patient Monitoring Record forms, dated 06/18/14 through 06/22/14, revealed facility staff had documented they had monitored Patient #1 every 15 minutes. On 06/22/14, Registered Nurse (RN) #2 documented Patient #1 had been observed to exhibit seizure-like activity, had a loss of bladder control, did not respond to verbal stimulation, and was transferred to the ED.

A review of the ED record dated 06/22/14 revealed ED staff assessed Patient #1's mental status at 7:30 PM and noted the patient was lethargic, nonverbal, and responding to painful stimuli. Documentation revealed "psych staff" informed the ED staff that Patient #1 had possibly consumed multiple bottles of hand sanitizer. In addition, "toxicology results" from the laboratory revealed the patient's blood alcohol level was "327 CH," with a reference range noted to be "0-10" (review of information obtained from "The Merck Manual" revealed a blood alcohol level of "300 to 400" often causes unconsciousness). Documentation revealed the ED physician intubated the patient and placed him/her on mechanical ventilation due to acute respiratory failure at 7:34 PM and requested the patient be transferred to the ICU. Continued interviews and review of documentation revealed upon Patient #1's transfer to the ICU, he/she was monitored, removed from mechanical ventilation on 06/23/14, and discharged from the ICU and the facility on 06/24/14.

On 06/26/14 (two days after Patient #1's discharge from the facility), observation of patient rooms on the same unit where Patient #1 was initially admitted revealed containers of lotion in rooms 324, 325, 327, 330, 331, 332, 333, 335, 343, 344, 345, and 346 that were available for patient use. Observation of the lotion containers revealed the lotion contained cetyl alcohol and benzyl alcohol; however, the percentages of the alcohol were not provided on the container.

A telephone interview was conducted with Patient #1 on 06/26/14 at 4:15 PM and revealed on 06/22/14, he/she observed a nurse use hand sanitizer at the nurses' desk and observed the nurse place the hand sanitizer on the desk. Continued interview revealed the patient walked into the nurses' station, obtained four (4) bottles of the hand sanitizer, mixed it with water, and drank it. Although the patient reported staff checked on him/her "often," the patient stated he/she obtained the hand sanitizer and had mixed the sanitizer in a cup of water so it would look like he/she was just drinking water. Continued interview revealed Patient #1 flushed the empty bottles of hand sanitizer down the toilet.

Interview on 06/26/14 at 4:03 PM with Sitter #1 revealed the Sitter monitored Patient #1 on 06/22/14 and the patient had been "fine" until approximately 7:00 PM when she observed the patient "slumped" in the chair with "seizure like" activity. According to the Sitter, she immediately informed the nurses of the patient's condition and the patient was transferred to the ED. Continued interview revealed another patient reported that Patient #1 had drunk hand sanitizer.

Interview on 06/26/14 at 3:47 PM with Licensed Practical Nurse (LPN) #1 revealed the LPN had passed medication to patients on the psychiatric unit on 06/22/14 and stated at approximately 5:30 PM, Patient #1 asked for some hand sanitizer and she had handed the patient a bottle of hand sanitizer and kept passing medication. The LPN revealed she had continued with the medication pass and had forgotten to ask the patient to return the hand sanitizer to her. Further interview revealed if a patient requested hand sanitizer, staff was supposed to place a small amount of the sanitizer in the patient's hand. Continued interview revealed the hand sanitizer was kept behind the nurses' station and could easily be obtained by the patients.

Interview on 06/26/14 at 3:10 PM with Registered Nurse (RN) #1 revealed the RN was in shift report when Sitter #1 reported Patient #1 was having a seizure. Further interview revealed the nursing staff went out to check on the patient and the patient was having seizure-like activity and had urinated on him/herself. Continued interview revealed RN #1 contacted the patient's psychiatrist, and informed him Patient #1 was having seizure-like activity and that another patient reported the patient had drunk hand sanitizer. RN #1 stated the psychiatrist informed her he would call and inform the ED physician of the patient's condition and of the report that the patient had ingested the hand sanitizer. RN #1 acknowledged hand sanitizer was kept at the nurses' station and if a patient requested use of the sanitizer staff would dispense a small amount in the patient's hand. According to RN #1, staff was to keep the hand sanitizer in a drawer at the nurses' station and acknowledged patients could possibly obtain the hand sanitizer if the sanitizer had not been returned to the drawer.

Interview on 06/26/14 at 4:43 PM with House Coordinator #1 revealed she was notified by staff at approximately 7:00 PM that Patient #1 was having a seizure. The House Coordinator stated she went to the unit at approximately 8:00 PM, was informed the patient drank hand sanitizer, and instructed staff to conduct searches of patient rooms. As a result of the room search, staff discovered three (3) unopened bottles of hand sanitizer in Patient #1's room. The House Coordinator stated she instructed staff to not store the hand sanitizer in patient care areas. Further interview revealed the House Coordinator went to the ER and was informed the patients' blood alcohol level was "327" and high; however, according to the House Coordinator, the ED physician made a comment that a person would have to drink "a gallon" of hand sanitizer for a blood alcohol level "that high." The House Coordinator revealed she notified the Director of Nursing (DON) on 06/22/14 at approximately 9:00 PM, that Patient #1 had a seizure and was transferred to the ED. The House Coordinator stated she informed the DON that it had been reported Patient #1 had drunk hand sanitizer and had a high blood alcohol level, and was told to notify the Executive Director because he was in the building. The House Coordinator stated she notified the Executive Director of Patient #1's seizure activity and that the patient had been transferred to the Emergency Department. According to the House Coordinator, she also informed the Executive Director it had been reported that Patient #1 had drunk hand sanitizer, that his/her blood alcohol level was elevated, and that staff found three (3) unopened bottles of hand sanitizer in Patient #1's room. Further interview revealed the House Coordinator was instructed by the Executive Director to complete two separate incident reports (Class 1); one incident report of the observation of Patient #1's seizure activity and a second report that staff had found hand sanitizer in the patient's room.

Nurse Manager #1 acknowledged in an interview conducted on 06/26/14 at 4:25 PM that she had reviewed the incident report on 06/23/14 (one day after the incident occurred) and informed the DON she was concerned the incident should be a higher class due to Patient #1's elevated blood alcohol level. The Nurse Manager stated the DON informed her the patient had a "seizure" and the ED physician reported he felt like something else was going on to cause the high blood alcohol level because a person would have to drink a "gallon" of hand sanitizer to get a blood alcohol level "that high." Nurse Manager #1 stated she had documented on the incident report that Patient #1 was admitted to the medical center and that the physician had reported "a person would have to drink a "gallon" of hand sanitizer to get a blood alcohol level that "high." Further interview with the Nurse Manager revealed the hand sanitizer should not have been accessible by the patients on the psychiatric unit. The Nurse Manager revealed if a patient requested hand sanitizer, a small amount should have been applied in a patient's hand, and that a patient should have never been given a bottle of hand sanitizer.

Interview on 06/26/14 at 5:40 PM with the DON revealed she was made aware on the night of the incident that Patient #1 had a seizure and was sent to the Emergency Department due to a suspicion the patient drank hand sanitizer. The DON also acknowledged the House Coordinator had informed her of the patient's elevated blood alcohol level and that hand sanitizer was found in the patient's room. The interview further revealed the DON was aware the Executive Director was in the building and she had instructed the House Coordinator to inform the Executive Director of the incident. The DON revealed she did not remember the Nurse Manager reporting concerns to her about the incident. Further interview revealed on 06/24/14 during a meeting that was attended by the Director of Social Services, the Director of Psychology, and the Unit Nurse Managers, the Director of Psychology had asked what the facility was going do about the patient that "overdosed." The DON stated at that time she asked what patient had overdosed and was told Patient #1. According to the DON, she informed the Director of Psychology that Patient #1 had a seizure, and had not viewed the incident as an overdose because the ED physician had stated "something else" was going on with the patient because someone would have to drink a "gallon" of hand sanitizer to have a blood alcohol level "that high." Continued interview revealed the Executive Director held a meeting with the Administrative staff after he learned Patient #1 had been on a ventilator and, at that time, the facility initiated an investigation of the incident. The DON revealed "a memo" had been placed on the nursing units that instructed staff to store hand sanitizer in the "chart room" (behind the nurses' station with a locked door) and when a patient requested hand sanitizer to provide them a small amount on their hands and not to give the bottle of hand sanitizer to any patient. The DON reported that prior to the incident the hand sanitizer was stored in a drawer at the nurses' station.

Interview on 06/26/14 at 11:20 AM with the Executive Director revealed he was in the facility on 06/22/14 and was informed by the House Coordinator that Patient #1 had a seizure, was transferred to the ED, and that there were "rumors" that the patient had drunk hand sanitizer and that three (3) unopened bottles of hand sanitizer were found in the patient's room. The Executive Director stated the House Coordinator had also informed him of the patient's blood alcohol level. According to the Executive Director, he instructed the House Coordinator to complete two incident reports about the incident, one related to the seizure, and one related to the bottles of hand sanitizer being found in the patient's room. Continued interview revealed on 06/22/14 the House Coordinator informed him of the ED physician's comments about how much hand sanitizer would have to be ingested to reach the blood alcohol level that the patient was reported to have and that he "felt" it was "unrealistic" that the patient had ingested enough hand sanitizer to reach the level reported. Continued interview revealed the DON informed the Executive Director Patient #1 was intubated and placed on a ventilator as a result of the incident and, as a result of the additional information, he met with Administrative staff on 06/25/14 and reclassified the incident as a Class 3 incident and stated the facility initiated an investigation of the incident. The ED also acknowledged a "memo" had been placed on the nursing units to inform staff to store hand sanitizer in the "chart room."

Based on interview, record review, and review of the policy, "Supervision of Patients," it was determined the facility failed to ensure that a Registered Nurse (RN) supervised the nursing care, protected and promoted patients' rights, and failed to ensure patients did not have access to hazardous materials (hand sanitizer) for one (1) of ten (10) sampled patients (Patient #1). Interviews and review of documentation revealed on 06/22/14, Sitter #1 reported to nursing staff she observed Patient #1 slumped in his/her chair and that he/she exhibited seizure-like activity. Nursing staff assessed Patient #1, notified the physician of the patient's condition, and transferred the patient to the Emergency Department (ED) of the facility for further evaluation and treatment. Documentation in the ED record revealed nursing staff informed the ED staff that Patient #1 could have ingested hand sanitizer prior to the observed seizure-like activity, and the ED physician requested a blood alcohol level for Patient #1. A review of the patient's blood alcohol level revealed the patient's blood alcohol level was "327 CH" (with a reference range of 0-10). The ED physician intubated Patient #1, placed him/her on mechanical ventilation, and transferred the patient to the Intensive Care Unit (ICU) for further assessment/treatment. According to the interviews, other patients on the psychiatric unit reported prior to the incident they had observed Patient #1 ingest hand sanitizer and reported the hand sanitizer was available at the nurses' station. In addition, continued interviews and review of documentation revealed on 06/22/14, at approximately 8:00 PM facility staff searched Patient #1's room and found three (3) unopened bottles of hand sanitizer in Patient #1's room. Based on interviews with nursing staff, hand sanitizer was often stored at the nurses' station and within patient reach.

The failure of the facility to identify and protect patients from neglect and failure to provide a safe environment placed patients at risk for serious injury, harm, impairment, and/or death. Immediate Jeopardy was identified on 06/30/14, was determined to exist on 06/22/14, and is ongoing. The facility was notified of the Immediate Jeopardy on 06/30/14. In addition, it was identified on 06/17/14 during the course of a previous investigation (KY21832) that the Conditions of Participation at 42 CFR 482.13 Patient Rights and 42 CFR 482.23 Nursing Services were not met and the facility was placed on 23-day termination. Due to the Immediate Jeopardy identified on 06/30/14, the 23-day termination is ongoing.

Refer to A0395.

Based on interview, record review, and review of the policy, "Supervision of Patients," it was determined the facility failed to ensure that a Registered Nurse (RN) supervised the nursing care for one (1) of ten (10) sampled patients (Patient #1). Interviews and review of documentation revealed on 06/22/14, nursing staff on the psychiatric nursing unit assessed Patient #1 after Sitter #1 reported she observed the patient slumped in his/her chair and that he/she exhibited seizure-like activity. After the assessment, Registered Nurse (RN) #1 notified the patient's physician and transferred the patient to the Emergency Department (ED) of the facility for further evaluation and treatment. Documentation revealed ED staff assessed Patient #1 and, after nursing staff informed ED staff Patient #1 could have ingested hand sanitizer prior to the observed seizure-like activity, the ED physician requested a blood alcohol level for Patient #1 and received "toxicology results" from the laboratory that revealed the patient's blood alcohol level was "327 CH" (with a reference range of 0-10). The ED physician intubated Patient #1, placed him/her on mechanical ventilation, and transferred the patient to the Intensive Care Unit (ICU) for further assessment/treatment. According to the interviews, other patients on the psychiatric nursing unit reported prior to the incident they had observed Patient #1 ingest hand sanitizer and reported the hand sanitizer was available at the nurses' station. Continued interviews and review of documentation revealed on 06/22/14, at approximately 8:00 PM facility staff searched Patient #1's room and found three (3) unopened bottles of hand sanitizer in Patient #1's room.

The failure of the facility to identify and protect patients from neglect and failure to provide a safe environment placed patients at risk for serious injury, harm, impairment, and/or death. Immediate Jeopardy was identified on 06/30/14, was determined to exist on 06/22/14, and is ongoing. The facility was notified of the Immediate Jeopardy on 06/30/14. In addition, it was identified on 06/17/14 during the course of a previous investigation (KY21832) that the Conditions of Participation at 42 CFR 482.13 Patient Rights and 42 CFR 482.23 Nursing Services were not met and the facility was placed on 23-day termination. Due to the Immediate Jeopardy identified on 06/30/14, the 23-day termination is ongoing.

The findings include:

Review of the facility's policy titled, "Supervision of Patients," revised May 2012, revealed patients should be placed on the appropriate level of supervision to assure the safety and well-being of the patient and others. In addition, the policy revealed all patients were monitored every 15 minutes, by assigned nursing staff, from the admission to the facility.

A review of the medical record revealed the facility admitted Patient #1 on 06/18/14 with diagnoses that included Depression, Opiate Abuse, and Possible Seizure. Based on documentation facility staff was to monitor the patient every 15 minutes in accordance with the facility policy. A review of Patient #1's Patient Monitoring Record revealed from 06/18/14 through 06/22/14 staff documented they had monitored Patient #1 every 15 minutes. However, a review of an incident report dated 06/22/14 at 7:15 PM revealed staff observed Patient #1 to have "seizure like" activity and was transferred to the ED. The Nurse Manager documented on the incident report on 06/23/14 (one day after the incident occurred) and noted staff observed Patient #1 exhibiting "seizure like" activity, sent the patient to the Emergency Department (ED) for evaluation and treatment, and the patient was admitted to the medical center of the facility. Continued review of incident reports revealed on 06/22/14 at 8:00 PM (45 minutes after the previous incident report), staff found three (3) bottles of "intact" hand sanitizer in Patient #1's room. Additional documentation on the incident report by Nurse Manager #1 on 06/23/14 (one day after the incident occurred) revealed Patient #1's room was searched after the patient was sent to the ED and staff found three (3) bottles of hand sanitizer in the patient's room. According to documentation on the report, the Nurse Manager informed staff to keep the hand sanitizer bottles in their pockets, in the medication room, or out of reach of patients.

Nurse's notes dated 06/22/14 at 7:15 PM confirmed nursing staff observed Patient #1 on 06/22/14 exhibiting seizure-like activity, and noted the patient had a loss of his/her bladder control, and did not respond to verbal stimuli. Further review of the nurse's notes confirmed the patient was transferred to the Emergency Department.

Documentation in the ED record on 06/22/14 revealed ED staff assessed Patient #1 and noted the patient was lethargic, nonverbal, and responding to painful stimuli. Continued review of the ED record revealed "psych" staff informed the ED staff that Patient #1 had possibly ingested hand sanitizer, and the physician requested a toxicology screen; based on the results of the toxicology screen, the patient's blood alcohol level was "327 CH", with a reference range noted to be "0-10" (review of information obtained from "The Merck Manual" revealed a blood alcohol level of 300 to 400 often caused unconsciousness). Documentation revealed the ED physician intubated the patient and placed him/her on mechanical ventilation due to acute respiratory failure at 7:35 PM and transferred the patient to ICU. Continued interviews and review of documentation revealed Patient #1 was discharged from ICU and the facility on 06/24/14.

An Interview conducted with Patient #1 on 06/26/14 at 4:45 PM revealed staff checked on him/her at least every 15 minutes. According to Patient #1, on 06/22/14, the patient observed a nurse obtain a bottle of hand sanitizer from a drawer behind the nurses' station. The nurse used the hand sanitizer at the nurses' desk and placed the sanitizer on the desk at the nurses' station. Patient #1 stated another patient was talking with nursing staff as a distraction and Patient #1 walked in to the nurses' station and took four (4) bottles of hand sanitizer. Continued interview with Patient #1 revealed the patient mixed the hand sanitizer with water and drank the mixture.

Interview on 06/26/14 at 4:55 PM with Patient #2 revealed the staff checked on the patients every 15 minutes. According to Patient #2, he/she saw Patient #1 go to the nurses' station and get the hand sanitizer while another patient was talking with the nursing staff as a distraction. Continued interview revealed Patient #1 had a cup of water and stated he/she had put the hand sanitizer in the water and drank the mixture.

Sitter #1 stated in interview conducted on 06/26/14 at 4:03 PM that she was assigned to monitor the 15-minute checks on Patient #1 on 06/22/14. Sitter #1 stated she had documented the monitoring and stated Patient #1 was "fine" until approximately 7:00 PM when she observed the patient "slumped" in the chair with "seizure like" activity. Sitter #1 stated she immediately informed RN #1 of the patient's condition on 06/22/14, and RN #1 contacted the patient's physician and the patient was transferred to the ED. According to the sitter, another patient on the unit had informed her that Patient #1 had drunk hand sanitizer prior to exhibiting the seizure-like activity.

Licensed Practical Nurse (LPN) #1 stated in interview conducted on 06/26/14 at 3:47 PM that the LPN had passed medication to patients on the psychiatric unit on 06/22/14 and stated at approximately 5:30 PM, Patient #1 asked for some hand sanitizer. LPN #1 stated she gave the patient a bottle of hand sanitizer, continued with the medication pass, and forgot to ask the patient to return the hand sanitizer to her. Further interview revealed if a patient requested hand sanitizer, staff was supposed to place a small amount of the sanitizer in the patient's hand. In addition, LPN #1 stated staff frequently kept hand sanitizer at the nurses' station and patients had easy access to the sanitizer if staff was not at the station.

Registered Nurse (RN) #1 stated in interview conducted on 06/26/14 at 3:10 PM that Sitter #1 was assigned to do 15-minute checks on Patient #1 according to the facility policy. According to RN #1, on 06/22/14 at approximately 7:00 PM, Sitter #1 informed her Patient #1 was having a seizure and when she went to assess the patient, she observed the patient was nonresponsive, was exhibiting seizure-like activity, and had urinated on him/herself. Continued interview revealed RN #1 contacted the patient's physician and informed him of the patient's condition and that another patient on the unit had reported the patient drank hand sanitizer prior to the seizure-like activity, and the patient was transferred to the ED for evaluation and treatment. RN #1 stated the hand sanitizer was stored in a drawer behind the nurses' station and acknowledged staff frequently stored the hand sanitizer on the desk at the nurses' station. According to RN #1, patients could possibly obtain the hand sanitizer by reaching behind the desk at the nursing unit if it was on the desk and not stored properly. RN #1 also stated if a patient requested use of the sanitizer, staff should dispense a small amount in the patient's hand and not give the bottle to the patient.

The Director of Nursing (DON) stated in an interview conducted on 06/26/14 at 5:40 PM that she had been made aware on 06/22/14 that Patient #1 had a seizure and was sent to the Emergency Department due to a suspicion that the patient drank hand sanitizer. The DON revealed the RN should have ensured the hand sanitizer was kept behind the nurses' station and in a drawer that was not easily accessible to patients. In addition, the DON also acknowledged staff had informed her hand sanitizer was found in the patient's room. The DON revealed "a memo" had been placed on the nursing units that instructed staff to store hand sanitizer in the "chart room" (located behind the nurses' station); and when a patient requested hand sanitizer to provide them a small amount on their hands and not to give the bottle of hand sanitizer to any patient. However, observations conducted on 06/26/14 (two days after Patient #1's discharge from the facility) revealed containers of lotion that contained cetyl alcohol and benzyl alcohol were found in patient rooms 324, 325, 327, 330, 331, 332, 333, 335, 343, 344, 345, and 346 and were available for patient use.

The Executive Director stated in an interview on 06/26/14 at 11:20 AM that on 06/22/14 at approximately 9:00 PM he had been informed by the House Coordinator that Patient #1 had a seizure and was transferred to the ED. The Executive Director stated there had been "rumors" that the patient had drunk hand sanitizer and that three (3) unopened bottles of hand sanitizer were found in the patient's room. The Executive Director stated the House Coordinator had also informed him of the patient's elevated blood alcohol level. According to the Executive Director, a "memo" had been placed on the nursing units to inform staff to store hand sanitizer in the "chart room."