Health inspection·August 18, 2023

42 CFR § 483.25(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. 42 CFR § 483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at § 483.10(c)(2) and § 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under § 483.24, § 483.25, or § 483.40. 22 Cal. Code Regs. § 72311. Nursing Service - General (a) Nursing Service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. The Department received a complaint that a resident had died on October 16, 2022. On 5/30/23 at 8:40 A.M., an unannounced visit was conducted at the facility to investigate the death of the resident (Resident 1). The Medical Doctor found Resident 1 with possession of vials with white powder and a needle. Various facility staff documented their concerns that Resident 1 may be accessing his PICC line (peripherally inserted central line - a flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) for illegal drug use. However, there was no documentation indicating that the facility developed a care plan or implemented interventions to address this concern. On 10/16/22, Resident 1 died at the facility and the Medical Examiner's report indicated the cause of death was "complications of acute (sudden onset) and chronic (continuing over a period of time) substance use disorder... self-administered methamphetamine (a potent nervous system stimulant) and recently fentanyl (a potent synthetic opioid pain reliever)." The facility failed to: 1. Ensure that Resident 1's environment remained free of unprescribed controlled substances that present an accident hazard. 2. Provide adequate supervision of Resident 1 to ensure that Resident 1 did not use unprescribed controlled substances while admitted to the facility. 3. Develop a resident centered plan of care with interventions that specifically addressed monitoring Resident 1's unsupervised departures from the facility, accessing controlled substances, and care and needs related to substance use disorder (SUD) (recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home). As a result, Resident 1 obtained and used unprescribed methamphetamine (a potent nervous system stimulant) and fentanyl (a potent synthetic opioid pain reliever) while admitted to the facility and died at the facility. The Death Certificate report indicated Resident 1's blood sample was positive for oxycodone and nor-fentanyl (narcotics). Findings: A record review of Resident 1's undated Admission Record indicated the resident was admitted to the facility on 9/16/2022, with diagnoses that included low back pain, other psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), insomnia (the presence of an individual's report of difficulty with sleep), and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act). A record review of Resident 1's care plan dated 9/21/22, indicated, "I am at risk for adverse reaction r/t [related to] potential IV (intravenous - a way of giving a drug or other substance through a needle or tube inserted into a vein) drug use while here at (name of facility)." A record review of Resident 1's care plan dated 9/22/22 indicated "[Resident 1] went out unnoticed with a PICC line resulting in potential for injury." A record review of the Resident 1's nursing Progress Note written by Licensed Nurse (LN) 1 dated 9/21/22 indicated, " ...noticed resident present with droopy eyes, slurred speech and sluggish like movement with a flush syringe connected to his PICC line, resident has a history of IV drug use and writer called RN (registered nurse) supervisor and charge nurse to assess patient as patient appeared 'high.' When RN's [sic] went to assess resident, resident then got up and started exercising and exhibiting erratic (unpredictable) behavior that is not within baseline (a starting point used for comparison), resident MD (medical doctor) made aware and a N.O. (new order) for a toxicology screen (the scientific study of adverse effects that occur in living organisms due to chemicals) ordered; lab (laboratory) called and made aware." A record review of Resident 1's physician's order dated 9/21/22 indicated, "toxicology lab R/T potential substance abuse." A record review of Resident 1's Test Request Form dated 9/23/22 indicated that Resident 1 refused to provide a sample for the ordered toxicology screening. A record review of Resident 1's Test Request Form dated 10/12/22 indicated that a urine specimen was obtained for toxicology screening. On 7/11/23 an email was received from medical records at the facility which indicated the lab ran a culture and sensitivity (a culture is a test to find germs that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) instead of a toxicology screen. A record review of Resident 1's nursing Progress Note written by LN 1 dated 9/22/22 indicated, "Resident was found coming into the building by station one staff from outside the facility; resident has a PICC line for IV abt (antibiotic); st (station) 1 nurses called st 2 and notified staff here; resident approached by charge nurse and writer to ask why the resident was outside, resident replied 'to get cell service.' Resident made aware that due to the PICC line and current drug abuse history, resident should not be stepping out outside [sic] without an order or someone to supervise to prevent injury; resident stated 'ok...'" A record review of the nursing Progress Note written by LN 2 dated 9/24/22 at 9:03 P.M. indicated, "[Resident 1] PICC line was noted to be clogged when RN attempted to do initial flushing. RN stopped and notified the MD immediately." A record review of the nursing Progress Note written by LN 3, dated 9/30/22 at 12:30 P.M. indicated, " [Resident 1] PICC line was noted clogged when to do [sic] initial flushing prior to the IV medication. Stopped immediately and notified NP." A record review of the Physical Medicine Rehabilitation Consultation/Initial Evaluation dated 10/11/22 indicated, "Date of Service 10/11/22. [MD 2's name]...Nursing staff notably expressing concerns for possible active drug use given his (Resident 1) PICC line being clogged on numerous occasions." A record review of Resident 1's nursing Progress Note written by LN 4 dated 10/16/22 indicated that on 10/16/22 at 12:55 A.M., "Resident found moaning and saying 'I' m in pain' and IV line disconnected from PICC line port and PICC line clamped (had been connected earlier). 103a (1:03 A.M.) resident found gasping for air and nonresponsive. Placed on oxygen 10 liters via non-rebreather mask (a medical device that helps deliver oxygen in emergency situations). 104am (1:04 A.M.) no pulse palpable (capable of being felt) CPR (cardio-pulmonary resuscitation - an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) begun and paramedics called. 110 (1:10 A.M.). Narcan (used for the treatment of life-threatening opioid overdose or suspected opioid overdose) 4 mg (milligrams) given x2 (two times) nasally. CPR continues and paramedics arrive at 112 (1:12 A.M.). 140am (1:40 A.M.) CPR ceased and paramedics pronounced resident deceased. ..." A record review of Death Certificate Amendment Worksheet from the Medical Examiner's Office dated 6/22/23 at 4:39 P.M. listed the cause of death as "complications of acute and chronic substance use disorder. Manner of death: accident. Place of injury: (address of facility). Date and time: 10/15/22 time unk (unknown). How occurred: self-administered methamphetamine and recently fentanyl." The report indicated that central blood (blood near the center of the body, often near the heart) was positive for fentanyl, methamphetamine, oxycodone (an opioid pain reliever), norfentanyl (substance the body makes as it breaks down fentanyl) and 4-ANPP (an impurity found in fentanyl preparations). The report indicated that peripheral blood (blood away from the center of the body, such as the arms or legs) was positive for oxycodone and norfentanyl. On 6/6/23 at 10:39 A.M., an interview and concurrent record review of the nursing Progress Note dated 9/21/22 was conducted with the Nurse Practitioner (NP). The NP stated Resident 1 had a history of leaving facilities against medical advice. The NP stated, "The resident was a big risk for overdose." The NP reviewed Resident 1's nursing Progress Note dated 9/21/22 when nursing staff had observed Resident 1 appeared to be "high" and had a flush syringe connected to the PICC line. The NP stated no other orders were written in response to Resident 1's change of condition on 9/21/22. The NP stated no one to one (1:1) monitoring was ordered. The NP stated the resident was not transferred to a higher level of care. A concurrent record review of the Social Services note dated 10/14/22 was conducted. The Social Services note indicated, "There had been concerns mentioned due to patient having IVs and PICC line. NP expressed concerns with patient going out on pass while on IV medications ..." The NP stated he did not feel comfortable granting Resident 1 a one-time pass to leave the facility for a family wedding On 6/6/23 at 3:10 P.M., an interview was conducted with MD 1. MD 1 stated, "I saw the resident fiddling around with something and he put it in his pockets. I expressed concern about his behavior and SUD. He said 'I'm not using. If I was you guys wouldn't know'. He had vials of white powder or a bag and a needle. He was here for treatment of infection, there was nothing else to treat. This is what drug addicts do. He's not in prison. We can't control everything he did. Just read my notes. He's only here for treatment of IV antibiotics for infection. Someone could have brought him something. He could have gone out and gotten something. We know he left the building once. ..." On 6/9/23 at 12:02 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated there were no measures put in place to prevent Resident 1 from leaving the facility without the knowledge of the staff. The DON stated Resident 1 leaving the facility put the resident at risk for harm. On 6/9/23 at 2:45 P.M., an interview was conducted with the DON. The DON stated the resident should not have had access to a syringe. The DON stated there was a duty to keep the resident safe. The DON stated the facility did not do 1:1 monitoring. The DON stated there was a toxicology lab related to potential substance abuse ordered by MD 1 on 9/21/22. The DON stated the resident refused to give a urine sample on 9/22/22 so the test was reordered. Another toxicology lab was ordered on 10/12/22 which was collected. The DON stated there was no facility investigation of the death. On 7/5/23 at 8:51 A.M., an interview and joint record review of Resident 1's nursing note dated 9/21/22 was conducted with LN 1. LN 1 stated she called the RN into the room to show her "a flush syringe attached to (Resident 1's name) left arm PICC." LN 1 stated "The resident wasn't presenting how he usually presented." LN 1 stated that when the RN came into the room the resident started exercising and his behavior was erratic. LN 1 stated she called the charge nurse and RN supervisor in so they could assess him. LN 1 stated she called the NP and received an order for toxicology. LN 1 stated there were no notes showing increased monitoring or transfer to a higher level of care. LN 1 reviewed Resident 1's nursing note dated 9/22/22 at 2:17 P.M. LN 1 stated Resident 1 was seen coming back into the facility. LN 1 stated no one knew how long the resident was gone. LN 1 stated there was a potential for injury because Resident 1 had a PICC line. LN 1 stated, "That was the only time Resident 1 left on my shift." LN 1 stated she notified the NP and got an order for toxicology. LN 1 stated Resident 1 requested pain medication as soon as he could have it. LN 1 stated Resident 1 could not have been gone more than 4-5 hours based on the medication administration time. LN 1 stated Resident 1 received a medication between 9 A.M and 10 A.M. on 9/22/22 and returned to the facility at 2:17 P.M. LN 1 stated she wrote a care plan on 9/22/22 after Resident 1 returned to the building regarding "(resident name) went out unnoticed with PICC line resulting in potential for injury." LN 1 stated a second care plan was written on 9/22/22 regarding potential for injury. LN 1 stated there was no care plan written for substance use disorder for Resident 1 upon admission. LN 1 stated that interventions that addressed Resident 1's behavior of leaving the building unattended were not initiated until 9/22/22. LN 1 stated she created an IV drug use care plan only after Resident 1 eloped on 9/22/22. LN 1 stated the goals and interventions were template selections and were not individualized. LN 1 stated the interventions documented for wandering behavior, attempt diversional interventions, walking inside and outside, reorientation strategies including signs, pictures and memory boxes were part of the template selection. LN 1 stated the interventions did not fit Resident 1 and should have been more individualized regarding his age and interests. On 7/6/23 at 11:41 A.M., an interview and concurrent record review was conducted with the DON. The DON stated there was no care plan for substance use disorder created for Resident 1. On 7/11/23 at 10 A.M., an interview was conducted with LN 4. LN 4 stated, "...nurses would find his IV disconnected, they would find paraphernalia (equipment used for taking illicit drugs) at the bedside such as syringes. There was a comment made to the nurses not to leave any syringes because we believe he might be using his PICC line to shoot up drugs through, at one point an order for a drug screen was made to look for street drugs. I don't know the results of that test. I found a plastic syringe near the bedside the night of the code, it was one of our 10 cc (cubic centimeter - a unit of measurement) normal saline (sterile salt water for injection) syringes, empty, it appeared to have a white residue in a scant amount. He could get syringes if a nurse carelessly threw the syringe into the trash by his bedside. I dispose of syringes in the sharps container depending on if there's blood or wound irrigation (the steady flow of a solution across an open wound surface to ac