One dead, and two are hospitalized after seniors were given dishwashing soap instead of juice, that is the headline, wow! According to the article on CBS news, police are investigating the fatal poisoning at a San Mateo care facility. How could this happen? Sure, we have all read stories of residents finding toxic substances left unattended and consuming them, but to “serve” dishwashing soap to 3 residents? The good news is that the center immediately reported the event and began an internal investigation. 

As HealthCap risk managers travel the country, we see a lot of things outside of the “norm.” There are centers finding ingenious ways to cut costs while maintaining a safe environment for their residents. Community shower soap and shampoo dispensers are now the “norm,” no more individual bottles floating around asking for trouble. On the flip side, we see medicine cups filled from these community dispensers, left sitting on counters in bathrooms where a resident living with dementia can easily consume the contents. Filling unlabeled containers with cleaning solutions from a larger container for convenience or cost savings is probably not a great idea. Is that what happened in this case? That isn’t clear, however, I can tell you that we see this practice frequently.  

Let’s be proactive, don’t put your residents at risk of consuming caustic solutions. It might be time to schedule a reality check with your interdisciplinary team. Spot check janitor closets, dietary, housekeeping, laundry, are there chemicals in unlabeled containers or containers with handwritten labels on them? Check for hand sanitizer bottles, are they floating around resident care areas, or do you have enough dispensers throughout the building so staff don’t need to carry personal bottles? Bottom line, educate, educate, and if your staff aren’t aware of the risks, it might be time to re-educate. It isn’t easy, everyday there is another wrinkle, however, do the right things for the right reasons! Stay well and stay informed!