The California nursing facility where two residents died in August 2022, after accidentally being served dishwashing fluid, is now facing a large fine and the threat of losing its license. Two residents at the facility, both 93, died last year after they allegedly drank toxic dishwashing fluid mistakenly served as cranberry juice. The employee that was accused of pouring the fluid into a beverage container was charged April 11, 2023, with two counts of felony involuntary manslaughter and three counts of felony elder abuse.
The facility is now facing legal action from the State of California. The Department of Social Services website states that revocation action is pending as of March 7. A facility evaluations report filed on March 21 says that the department’s accusations supporting the pending license revocation and de-certification have been distributed to residents, the people responsible for them, and a local ombudsman.
Another evaluation report, which cites the facility for the August poisoning incident, was filed on April 14. The report states that the facility’s employees weren’t properly trained on how to handle potentially dangerous chemicals. The facility was issued a $39,500 fine which includes $15,000 per death as a result of the incident, and $10,000 based on the additional resident that was hospitalized as a result. The facility had already paid $500 after an immediate fine was issued during a February visit.
The Department has visited the facility five times in the first four months of 2023. It visited the facility seven times in 2022, with six of those visits coming after the incident on August 28.
Compliance Perspective
Issue
The most common sources of chemical contamination of food are cleaning agents (such as glass cleaners, soaps, and oven cleaners) and insecticides. Chemicals used by facility staff, in the course of their duties, may contaminate food (e.g., if a spray cleaner is used on a worktable surface while food is being prepared, the food becomes exposed to a chemical). An inadequately identified chemical may be mistaken for an ingredient used in food preparation. For example, incorrectly stored (e.g., dishwashing liquid stored in a syrup bottle) or unlabeled (e.g., white granulated cleaner that looks like salt) cleaning products may be inadvertently added to food and drinks and cause illness. Chemical products and supplies must be clearly marked as such and stored separately from food items.
Discussion Points
- Review policies and procedures regarding the use and storage of foods and drinks to ensure safe and sanitary storage, handling, and consumption. Policies and procedures should also be in place for safe and separate storage of chemicals away from food and drink storage, preparation, and handling areas to prevent contamination that could compromise food and drink safety.
- Food service employees should receive training related to compliance with safe chemical storage apart from food storage and preparation areas. They should also receive education on sanitation and safety protocols and the use of safe food handling and storage practices to prevent cross contamination.
- Periodically audit to determine if concerns are identified with the safe storage, handling, or service of food and drinks away from chemicals. Audit food storage practices to ensure that food and drinks, including ice, are not at risk for biological, chemical, or physical contamination.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
