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Based on policy review, medical record review, and interview, the facility failed to ensure patients rights were protected and patients received care in a safe setting by failing to follow the hospital's policy regarding proper labeling of chemicals when 1 of 3 (Patient #1) sampled patients reviewed, was given and ingested a cup of clear liquid poured from an unlabeled pitcher which was actually filled with a diluted chemical cleaning solution that Registered Nurse A mistook for water.

The findings include:

Patient #1 was seen in the Emergency Department (ED) on 3/26/2025 for an upper Gastrointestinal (GI) Bleed. Patient #1 was subsequently admitted to the Intensive Care Unit on 3/26/2025. On 3/28/2025 Patient #1 was assigned to Registered Nurse A. Registered Nurse A went into the nourishment room to get Patient #1 a cup of water. Registered Nurse A picked up an unmarked clear pitcher sitting on the counter, poured the liquid into a cup over ice and served it to Patient #1. Patient #1 drank the entire amount. Patient #1 subsequently required a second bronchoscopy due to ingesting a chemical substance with a GI Bleed.

Refer to A-0144

Based on policy review, medical record review, review of a disclosure event note, and interview, the facility failed to ensure patients rights were protected, and the patients received care in a safe setting when 1 of 3 (Patient #1) sampled patients reviewed was given and ingested a cup of clear liquid poured from an unlabeled pitcher filled with a diluted chemical cleaning solution that Registered Nurse A mistook for water.

The findings include:

1. Review of a policy titled, "Hazardous Chemical Right-to-Know/Hazard Communication" dated February, 2023, revealed, "...To provide a process by which chemicals stored or used... are identified and that information concerning the hazards are communicated to Workforce Members, non-employed medical providers with privileges, regulatory/accrediting agencies, and emergency responders, as required... Specific Education... New staff receive mandatory... training during general orientation...This training includes... Location and availability of this policy... Requirements for chemical container labels and SDS [Safety Data Sheet]... Physical and health hazards of hazardous chemicals... Protective measures staff use, which include work practices... Training is customized to address the hazardous chemicals maintained or utilized in individual areas and includes... Physical, health, and other hazards associated with exposure to chemicals in the work area... Labeling: Hazardous chemicals removed from original containers and placed into new containers are labeled with the hazard information consistent with that of the original container. Information on the new secondary container includes... Product identification or material name... Supplier identification (name of manufacturer or distributor, address, and emergency phone umber) and... A signal word, pictogram, hazard statement, and precautionary statement for each hazard class and category..."

2. Patient #1 was seen in the Emergency Department (ED) on 3/26/2025 reporting nausea and abdominal pain with Gastrointestinal (GI) Bleeding. Patient #1 was subsequently admitted to the Intensive Care Unit (ICU) on 3/26/2025 with diagnoses to include Esophageal Varices, and Gastroesophageal Reflux Disease (GERD).

Review of a Disclosure Event Note dated 3/28/2025 signed by Advanced Practice Nurse C revealed, "...Date and Time of Disclosure Discussion: 3/28/2025 at approximately 10:45am... Location of Disclosure Discussion: Patient's room ICU... Patient was present. No family members present. Date and Time of Event: 3/28/2025 at 10:15 [AM] Location of Event: ICU... I was approached by the task Nurse [named Registered Nurse A] who informed me that the patient had accidentally been given cleaning sanitizer that she retrieved from a drink pitched next to the water/ice machine in the ICU nourishment room. The patient drank the entire 8oz[ounces] cup of liquid. The Nurse then went back to the refreshment room to get water for another patient and saw that the maintenance staff member was pouring the liquid from the pitcher into the ice/water machine. The nurse asked the maintenance worker what was in the pitcher. He informed her that was a machine sanitizing solution. She informed him that she had given a patient this fluid. 1.6ml [milliliter]of solution was mixed in one gallon of water and 8oz [ounces] was given to the patient. [Named Nurse A] then approached me. I had just exited the patient's room and he was not in any discomfort. I immediately called poison control. Given he had four esophageal varices banded yesterday and the caustic property of the solution, poison control recommended NGT [NasoGastric Tube - a tube inserted through the nose into the stomach to suction material a patient has ingested or the instill nutrition is a patient is unable to swallow] insertion, evacuation of the fluid from the stomach and repeat endoscopy in 12-24 hours while monitoring closely for bleeding...I entered the room with [Named Physician]...[Named Physician] and I informed the patient of his accidental ingestion of this cleaner. He was appropriately shocked. We told him that we believed that the nurse thought she was giving him water from a pitcher and found out it was diluted cleaner after the fact. He said that he did not tasted anything "off" with the fluid. He agreed to the NGT placement and asked for the smallest NGT possible. we offered an apology and said that we were continuing to investigate the cause of exactly how this happened, but didn't have all the answers just yet but need to act urgently given the time sensitivity of evacuating the fluid from his stomach...NGT was placed without event with removal of approximately 200cc [cubic centimeter] clear fluid...I provided an update to his daughter...who was very understanding. Her biggest concern is her father's discomfort coming off conscious sedation and she is worried about repeat endoscopy and further discomfort. I informed her that he would be monitored in the ICU through the weekend...Copy of this note provided to his daughter and former wife, at their request..."

Review of the upper GI endoscopy results dated 3/30/2025 revealed, "Preoperative Diagnosis: Exclusion of esophageal injury due to caustic ingestion...Postoperative Diagnosis...Esophageal ulcers with no stigmata of recent bleeding...Findings...Three superficial esophageal ulcers with no stigmat [a specific diagnostic sign of a disease] of recent bleeding were found in the lower third of the esophagus....The upper third of the esophagus and middle third of the esophagus were normal. No evidence of caustic esophagitis or esophageal mucosal necrosis...Signed by Physician B on 3/30/2025 at 10:47:43 AM..."

Review of Physician's Assessment dated 3/30/2025 at 10:50 AM revealed, "Condition: In stable condition. Unchanged. (Upper GI bleeding-post banding x4. Caustic ingestion noted. Repeat upper endoscopy today with no bands in place...No evidence of esophageal necrosis related to caustic ingestion)..."

Review of the Discharge Summary dated 4/2/2025 revealed, "...Primary Diagnosis: GI bleed... Additional discharge Diagnoses...Accidental ingestion of cleaning solution...HOSPITAL COURSE...Notably, on 3/28 [2025] a disclosure event had occurred and patient had accidentally been given cleaning sanitizer that nursing staff had received from a drink picture [pitcher] next to the water/ice machine...Patient had consumed 8 ounces of a cup of liquid. Poison control was immediately contacted and NG [NasoGastric tube] was placed for evacuation of fluid from the stomach. A repeat endoscopy was performed 3/30 [2025] that showed no evidence of caustic injury prior esophageal varices without stigmat of recent bleeding...was ultimately transferred out of the ICU on 3/30 [2025]..."

During a telephone interview on 5/1/2025 beginning at 11:57 AM, Registered Nurse (RN) A was asked what happened when Patient #1 was given a chemical solution by mistake. RN A stated, she went into the nourishment room to get a cup of ice water for a patient. She stated there was a maintenance man in the room on a ladder doing maintenance on the water/ice dispensing machine. She stated she poured the water from an unmarked clear pitcher that was on the counter and gave it to Patient #1. She stated he drank all of it which was in an 8 oz cup. She stated she went back into the nourishment room to get another cup of water for another patient and saw the maintenance man pouring the liquid from the pitcher into the water/ice dispensing machine. She stated the maintenance man told her it was a sanitizing chemical solution in the pitcher. She stated she immediately notified the Nurse Practitioner and the poison control center was called.

During an interview on 5/1/2025 beginning at 12:04 PM, the Heating, Ventilation and Air Conditioning (HVAC) Mechanic was asked what he was doing in the nutrition room when Patient #1 was given the chemical solution by mistake. The HVAC Mechanic stated he was in the nourishment room in the ICU doing preventative maintenance on the water/ice dispensing machine. He confirmed there was no signage posted on the doors to the nourishment room notifying staff. He confirmed RN A came into the nourishment room. He stated he did not see RN A pour any liquid into the cup.

During an interview on 5/1/2025 beginning at 12:53 PM, The Chief Nursing Officer and the Director of Plant Operations were asked if an Ad Hoc (for this situation) Quality Assurance Process Improvement (QAPI) meeting and Governing Body meeting was held and if so, what was the outcome of the meetings. The Chief Nursing Officer stated they call QAPI a "Safety Event Analysis" meeting. The first debriefing meeting date was 3/28/2025 and also included ICU staff on site that day. They had a second meeting on 4/4/2025 and a third meeting on 4/15/2025. They constructed a plan of correction immediately which was documented and a copy was provided. The Director of Plant Operations stated some of the immediate interventions would be all maintenance personnel will provide purchased water bottles to any area when the water/ice machine is taking down for maintenance. The maintenance personnel will communicate with the Charge Nurse and notify them of the preventative maintenance to be done. The plan also included making laminated signs to put outside the doors when maintenance was being done. A sign was provided and read, "Preventative maintenance in progress. If there are questions, please see Charge Nurse." Education was provided beginning on 3/28/2025 for the maintenance staff and continued to expand the education to the Lab personnel. Nursing staff education was ongoing. The Chief Nursing Officer stated their policy was reviewed and no changes were made to the policy. She stated the policy review was part of the education. The Chief Nursing Officer also stated, the computer training was reviewed and provided a copy of a slide that documented, "If you move a chemical to a new container, you must copy what was listed on the first container onto a label for the new container. This lets everyone know if the chemical might be dangerous. The Office of Clinical and Research Safety (OCRS) website has resources to help you make your own labels that comply with the regulations." The Chief Nursing Officer stated the Governing Body was notified regarding the incident.

During a telephone interview on 5/20/2025 beginning at 11:41 AM, Patient #1 stated, "...No one expected that to happen with the cleaning solution...That put me over the edge. I was extremely nervous and kind of anxious about the whole thing. I see a counselor, and that's been the only thing we've talked about since I've left that hospital...Now, I'm a little more terrified of that thinking about how easily something went wrong...They put a tube up my nose down into my stomach to pump...out...But how I felt after that was panic. I was shaking all the time..."
Patient #1 was asked if a representative from the hospital did any follow up after discharge. Patient #1 stated, "...I got a call from administration at the [Named Hospital] telling me...they were really sorry to hear that happened and they were looking into it...So I had to have a second endoscopy within a couple days of being there..."