S1 refilled the one-gallon bottle of dishwasher soap on at least two occasions while assigned to Section 1, a few weeks prior. S1 used the same beverage pitcher to transfer soap from the five-gallon bucket in the large kitchen to the existing one-gallon in the small kitchen.

S2 agreed to pour the soap into the beverage pitcher that S1 had selected. While S1 and S2 were filling the beverage pitcher with soap, S3 witnessed S2 transfer the soap into the pitcher and S1 took the pitcher from S2. S3 failed to report what S3 saw.

S2 left the pitcher with S1 and failed to confirm the transfer occurred. S1 did not pour the detergent into the one-gallon detergent dispenser right away and instead left the pitcher on the counter, next to the sink. Per video footage, the beverage pitcher with soap was within one foot of the coffee maker, two feet of bananas in a small storage rack on top of the counter, three to four feet from the toaster, and five feet of the juice maker.

S4 picked up the beverage pitcher and served R1, R2, and R3, not knowing the beverage pitcher contained the dishwasher soap. R1’s lips began to swell and was black and red in color. R2 yelled after drinking out of the juice cup and then sat down. S1, said “it’s soap.” S4 was confused as the soap was the same color as cranberry juice. S4 asked other staff to call 911. S4 did not know when poison control was supposed to be called.

Upon observing R1, R2, and R3 were having an adverse reaction, facility staff members called 911. San Mateo Consolidated Fire Department (SMCFD) and AMR (medical transportation) arrived, in response to the call. S5, who was the manager on duty, stated to the Fire Chief that a Resident went into the kitchen and poured glasses of the dishwashing detergent/chemicals and gave them to other Residents to drink. S5 and a member of SMCFD called Poison Control to inquire about the ingestion of the dishwashing detergent/chemicals by the residents. R1, R2, and R3 were all transported to nearby hospitals. R1 and R2 eventually died at the hospital shortly after ingesting the detergent/chemicals.

Later, when an investigating police officer spoke to S5, S5 originally told the investigating officer that he could not recall telling the Fire Chief that a Resident had served the detergent/chemicals to the other Residents. S5 then told the investigating officer that they told the Fire Chief that an employee had served the detergent/chemicals to the Resident. Later, S5 admitted to the officer that they had told the Fire Chief that a Resident had served the chemicals and that S5 was originally confused about who served the soap.

Review of medical records showed, due to negligence of facility staff S1, S2, and S3, R1, R2, and R3 sustained serious burns to their mouths, esophagus, and stomach leading to necrotizing tissue. Further, while acting as the manager on duty, S5 made false statements to responding emergency personnel and investigating officers, which mislead and/or impaired the investigation to the incident.

Based on interviews, and facility records, there were no instructions on how to pour the detergent from the five-gallon bucket to the one-gallon detergent dispenser. LG caregivers did not receive trainings for chemicals since they were not kitchen staff, even though they were assigned to kitchen duties.

The Department has completed the investigation of the above allegation. Based on the investigation that included staff interviews, facility surveillance video, review of medical records, police report, San Mateo County 911 audio recording and computer-aided dispatch report, staff records, personnel records review. The preponderance of evidence standard has been met for the above allegation, Neglect/Lack of Supervision – R1, R2, and R3 ingested poison while in care resulting in serious injury and/or death. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Immediate exclusion orders were issued for S1, S2, S3, and S5.

Deficiencies cited today under the California Code of Regulations, Title 22, Division 6, follows on LIC 9099D. An immediate civil penalty in the amount of $500 was assessed today for serious violation resulting to serious bodily injury of a resident and deaths of 2 residents. Additional civil penalties in the amount of $10,000 for the violation resulting in serious bodily injury and additional civil penalties in the amount $15,000 for each death of a resident are pending reviews. Non-compliance meeting will be scheduled. Exit Interview conducted. This report and rights to appeal were discussed with Administrator, Jennifer Duenas and a copy is provided.