Other·April 3, 2024

Driftwood Healthcare Center - Santa Cruz Abbreviated Survey (Y1BG11) Exit Date 3/4/2024 The following reflects the findings of the California Department of Public Health during the investigation of Complaint CA00852609 Event # Y1BG11 Representing the Department, HFEN 42819 State Citation A was written REGULATORY VIOLATION(S): Federal Code of Regulations Title 42 F689 §483.25 Quality of Care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patients' choices. (d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations Title 22 § 72311 (a)(2) Nursing Service (a) Nursing service shall include, but not be limited to, the following: ... (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 72523 (a) Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. From 7/27/23 to 3/4/24, unannounced visits were conducted at the facility to investigate a complaint regarding patient care made on 6/9/2023 and 6/12/2023. The facility failed to assign the recommended one-on-one staff to Resident 1 for adequate monitoring, as was required in the plan of action of the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients), following an incident on 6/9/23 where Resident 1 was found to have consumed an un-prescribed (not prescribed by a medical practitioner) Diazepam [Valium; a controlled medication to treat anxiety, alcohol withdrawal, and seizures (convulsions)]. [A controlled medication is a drug or substance that is tightly controlled by the government because of their abuse potential or risk, these medications are primarily active in the central nervous system (brain and spinal cord) and can cause physical and mental dependence leading to addiction, they can also have significant harmful health consequences at high doses.] This failure resulted in a subsequent incident where Resident 1 was found to have overdosed on un-prescribed Diazepam and was sent to the hospital on 6/12/23 via emergency medical services (EMS, a system that provides emergency medical care). FINDINGS Review of Resident 1's face sheet (summary page of a patients' important information) indicated, Resident 1 was admitted on 9/19/2022, with diagnoses included idiopathic progressive neuropathy (nerve damage that interferes with the functioning of the peripheral nervous system); emphysema (a lung condition that causes shortness of breath); spinal stenosis, cervical region (is when the neck area of your spine is narrow); spinal stenosis, lumbar region [lower back] without neurogenic claudication (the narrowing of the spinal canal in the lumbar region but is not causing the typical leg symptoms while walking or standing); generalized anxiety disorder (persistent and excessive worry that interferes with daily activities); major depressive disorder, recurrent (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/23/2023, indicated Resident 1's Brief Interview for Mental Status (BIMS, a cognitive assessment) score was 15 (a score of 15 indicates resident has intact cognition). Review of Resident 1's Nurses Progress Notes, dated 6/9/2023, at 6:16 a.m., indicated, "Charge nurse went into residents' room to check vital signs (an objective measurement of the body's most basic functions) and resident noted to have a bubble pack of Diazepam 10 milligrams (mg, unit of measure) on side of his pillow. There is 11 pills missing out of a pack of 20. Resident noted sedated. Vitals stable and WNL (within normal limits). Resident noted arrousdable (typo arousable). Md (Medical doctor) was contacted, message was left awaiting further orders." Review of Resident 1's Observation Detail List Report: Risk Meeting Notes Initial Week One, dated 6/9/23, " ...Resident consumed medication that was not prescribed ... On 6/9/23 at 0600 the Charge nurse went into residents' room to check vital signs and resident noted to have a bubble pack of diazepam 10 mg on side of his pillow. The nurse immediately confiscated the pills and secured them in a locked narcotics drawer (drawer to keep controlled drugs). The resident was assessed. All Vitals stable and WNL (within normal limits). The Doctor was notified ...IDT Plan of action: 1) Monitor resident for the next 72 hours for any s/sx (signs and symptoms) of being under the influence of illicit drug use. 2) Staff do thorough sweeps (search) of the room q (every) shift for any non-prescribed drugs. 3)recover and confiscate any drugs if found. Monitor resident q (every) shift for any signs or symptoms of illicit drug use. 4) monitor resident for any attempts to receive non prescribed drugs from any source ...7) One on one to monitor resident ..." Review of Resident 1's Nurses Progress Notes, dated 6/12/2023 at 1:31 p.m., indicated, "RESIDENT NOTED TO BE SEDATED AND SLURRING HIS WORDS. CHARGE NURSE WENT TO ASSESS RESIDENT FURTHER AND RESIDENT NOTED WITH A PACKET OF DIAZEPAM AT BEDSIDE PACK OF 20 WITH 3 LEFT IN PACKAGE. AS CHARGE NURSE WALKED IN RESIDENT 2 IN ROOM A WAS IN RESIDENT 1 ROOM AND RESIDENT 2 HANDED RESIDENT 1 A PILL AND RESIDENT 1 SWALLOWED IT AS NURSE ASKED FOR IT. MD (medical doctor) WAS CONTACTED AND ORDER TO SEND TO ER (emergency room) FOR FURTHER EVAL (evaluation) WAS GIVEN." Review of Resident 1's Nurses Progress Notes, dated 6/12/2023, at 3:16 PM, indicated, "Staff contacted 911 for this resident due to overdose of medication labeled as Diazepam. This resident has a documented DX (diagnosis) of depression and a history of suicidal ideation (thoughts and preoccupation with death and dying). The resident's VS (vital signs, an objective measurement of the body's most basic functions) were low per his baseline; BP 95/57 (blood pressure, the measurement of the pressure or force of blood inside your arteries, between 90/60 and 120/80 mmHg (millimeters of mercury) is considered ideal), RR 16 (respiratory rate, rate of breathing, normal rate is 12-18 breaths per minute for adults at rest) and O2 Sat 90% (oxygen saturation, indicates the percentage of oxygen in the blood and provides information about the functioning of the lungs, normal rate is 95% or higher) on rm (room) air (air we breathe which has 21% of oxygen). Staff assessed and determined the resident to be altered, drowsy, but rousable. Resident stated he felt "awful and dizzy." Staff was unable to determine with absolute certainty exactly what and how much drugs Resident 1 consumed. The EMT's (Emergency medical technicians, provide life-saving care to patients at the scene of an emergency and during transportation in an ambulance during transport to a hospital) assessed Resident 1 and transferred him out as a 5150 (allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for further monitoring and evaluation ..." Review of Resident 1's ED (Emergency Department) Physician Notes, dated 6/12/23, indicated: "Arrival mode: Ambulance....History of Present Illness: The patient presents with benzodiazepine (medication that produce sedation and hypnosis, relieve anxiety, and muscle spasms, and reduce seizures) overdose. This is a [age]-year-old male BIBA (brought in by ambulance) from [SNF name] to the ED (emergency department) on a 5150 hold...after a suspected 17mg ingestion of Valium around 1400 today. Per EMS (Emergency Medical Services), patient was seen by staff with the Valium bottle that originally contained 20 tablets and only 3 were left when they looked. Staff is not sure if the 20 tablets was the original amount of Valium. Patient is not prescribed the Valium ... Patient states he did not take the Valium. Per staff, patient is normally more alert and oriented, but is more lethargic (drowsy & lack of energy and mental alertness, a decrease in consciousness) .... Resp Rate (Monitor) rate 10 Breaths/Min (minute)" (respiration; breathing, how the air moves into and out of lungs. A normal respiration rate is 16 to 20 breaths per minute). During an interview with licensed vocational nurse A (LVN A) on 8/31/23, at 2:55 p.m., the LVN A stated she was the charge nurse when Resident 1 had an episode of medication overdose on 6/12/23. The LVN A stated Resident 1 had a small box of Diazepam found on his bedside table. The LVN stated it's not the same bubble pack (type of medication package) from the facility, and Resident 1 looked sedated that time. During a phone interview and concurrent record review with the staffing coordinator (SC) 12/5/23, at 2:05 p.m., the SC stated she assigns the one-on-one staff as communicated by the director of nursing (DON). The SC reviewed the Nursing Staffing Assignment and Sign-in sheet dated 6/9/23, 6/10/23, 6/11/23, and 6/12/23. The SC confirmed there was no one-on-one staff assigned to Resident 1 on these days. The SC stated that she did not assign a one-on-one staff for Resident 1 because she was not instructed to assign a one-on-one staff for Resident 1. The SC stated it is the DON who communicates with the SC (her) which residents need a one-on-one. During an interview and concurrent record review with the Director of Nursing (DON) on 12/8/23, at 12:00 p.m., the DON reviewed the Risk Meeting IDT notes dated 6/9/23. The DON confirmed the IDT's plan of action after Resident 1's suspected medication overdose on 6/9/23, included one-on one monitoring for Resident 1 and that there was no one-on-one staff assigned to Resident 1 following the suspected overdose episode on 6/9/23 until 6/12/23, when Resident 1 was transferred to the hospital for evaluation. The DON stated Resident 1's first episode of medication overdose occurred on 6/9/23 on a Friday. The DON stated the one-on-one monitoring IDT recommendation was not assigned timely. The DON stated it should be implemented because another medication overdose incident happened so quickly. The DON instructed the nursing staff (CNAs, charge nurses) to check Resident 1's room for medications and instructed CNAs to monitor the resident for anything suspicious. The DON stated the monitoring that was provided by the CNAs was on and off, in between their patient care duties. The DON stated it might not provide the same level of monitoring and supervision provided by the one-on-one staff who stay with and watch the resident all the time. The DON also stated Resident 1 was already being monitored for falls, sleep, pain, behavior, which the DON felt was already enough at that time. Upon review of the Alert charting notes and Nurse's progress notes, the DON confirmed there was no proof of documentation that the 72-hour monitoring was done by the nursing staff, after Resident 1's overdose episode on 6/9/23. The DON also stated that Resident 1 can be very sneaky and manipulative, and that Resident 1 was capable of hiding medications in his pocket or taking medications while in the bathroom. The surveyor inquired about implementing the one-on-one staff to Resident 1 due to his manipulative and sneaky behavior. The DON stated that providing one-on-one staff might help. The DON agreed that the reason the IDT recommended the one-on- one staff to monitor Resident 1 was to prevent the recurrence of the overdose incident from 6/9/23. Review of Review of Resident 1's Care Plan, dated 6/12/2023, indicated that Resident 1 had "Medication overdose. The interventions included health teaching on medication administration effect and benefits of medication including adverse effects, physiological referral..." It further indicated that "...Resident is taking medication that is not prescribed to him. The interventions included, consulted with MD for alternatives to evaluate if current regimen is effective. Offered resident drug rehab." Review of Resident 1's Physician's Order, dated 6/14/2023, indicated, "Monitor the resident for s/sx (signs and symptoms) of altered mentation due to overdose and or consumption of non-prescribed medication. Special instructions: For resident monitoring illicit drug use every shift...Routine room checks/sweeps for drugs and or medications not prescribed. Special instructions: For prevention of illicit drug use. Every shift..." Review of Resident 1's Observation Detail List Report: Risk Meeting Notes Initial Week One, dated 6/12/23, indicated, "...on 6/12/23 Staff contacted 911 for this resident due to overdose of medication labeled Diazepam (10 mg) ...Plan of Action: 1) The resident admitted to the hospital for self administered non prescribed medication overdose. 2) One on one for this resident upon return to the facility for monitoring and prevention of another incident of illicit drug use. 3) Out on pass (temporary permission for resident to leave the facility) revoked. Resident requires a facility designed chaperone to accompany him to all necessary appointments outside of the facility... 6) Q-shift (every shift) monitoring for s/s of being under the influence. 7) Q shift room sweep for narcotics. Q-shift monitoring for s/sx of emotional distress. 8) Q- shift monitoring for drug seeking behavior..." Review of facility's policy and procedure, titled, "Risk Meeting," dated 12/8/23, "The Risk Meeting is designed to bring current resident/patient issues to the interdisciplinary team for discussion, potential alterations to the care plan, notification to all disciplines regarding current status of residents/patients, and to develop proactive approaches designed to prevent acute episodes from occurring." Review of facility's policy and procedure, titled, "Safety Supervision of Residents," dated 9/24/23, indicated, "Individualized, Resident -Centered Approach to Safety...2.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently..." The facility failed to assign the recommended one-on-one staff to Resident 1 for adequate monitoring, as was indicated in the plan of action of the Interdisciplinary Team. This failure resulted in a subsequent incident where Resident 1 was found to have overdosed on un-prescribed Diazepam and was sent to the hospital on 6/12/23 via emergency medical services. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.