Other·November 2, 2023

Title 22, Division 5, Chapter 3, Article 5, Section 72523. Patient Care and Procedures (a) (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Title 42, Code of Federal Regulation § 483.40. Behavioral health services. Each Patient must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a Patient's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. (a) The facility must have sufficient staff who provide direct services to Patient with the appropriate competencies and skills sets to provide nursing and related services to assure Patient safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each Patient, as determined by Patient assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's Patient population in accordance with § 483.70(e). These competencies and skills set include, but are not limited to, knowledge of and appropriate training and supervision for: (1) Caring for Patient with mental and psychosocial disorders, as well as Patient with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to § 483.70(e), and (2) Implementing non-pharmacological interventions. (b) Based on the comprehensive assessment of a Patient, the facility must ensure that— (1) A patient who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. On August 15, 2023, at 2:58 p.m., an unannounced visit was conducted at the facility to investigate a complaint on patient's rights. It was determined that the facility failed to provide adequate surveillance of daily activities to seven patients (Patients 1, 2, 3, 4, 5, 8, and 9) observed to have behaviors of substance abuse and were found to have in their possession illegal drugs and paraphernalia. Patient 1 was suspected of receiving illegal drugs through his room window and suspected of dispersing the illegal drugs to Patients 2, 3, 4, 5, 8, and 9. These failures had the potential to cause serious harm such as accidental death to Patients 1, 2, 3, 4, 5, 8, and 9. A review of Patient 1’s medical record indicated the patient was admitted to the facility on July 26, 2022, with diagnoses which included diabetes mellitus type 2 (a chronic condition that affects the way the body processes sugar), stimulant dependence, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Patient 1’s “History and Physical,” dated July 28, 2022, indicated the patient had decision making capacity. A review of Patient 2’s medical record indicated she was admitted to the facility on May 5, 2023, with diagnoses which included quadriplegia, (paralysis from the neck down, including the trunk, legs, and arms), major depressive disorder, and anxiety disorder (a chronic condition characterized by an excessive and persistent sense of apprehension). A review of Patient 2’s “History and Physical,” dated May 11, 2023, indicated the patient had the capacity to understand and make decisions. A review Patient 3’s medical record indicated the patient was admitted to the facility on September 16, 2022, with diagnoses which included of psychoactive abuse with intoxication, depression, alcohol abuse with intoxication, and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Patient 3’s “History and Physical,” dated September 20, 2022, indicated the patient had decision making capacity. A review of Patient 4’s medical record indicated he was admitted to the facility on June 1, 2021, with diagnoses which included of diabetes mellitus type 1 (a chronic disease characterized by elevated levels of blood sugar), vascular dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), major depressive disorder, and stroke. A review of Patient 4’s “History and Physical,” dated January 10, 2023, indicated the patient had the capacity to understand and make decisions. A review of Patient 5’s medical record indicated the patient was admitted to the facility on December 19, 2021, with diagnoses which included of chronic pain syndrome, peripheral vascular disease (PVD - is a slow and progressive circulation disorder), and major depressive disorder. A review of Patient 5’s “History and Physical,” dated October 14, 2021, indicated decision making capacity was intact. A review of Patient 8’s medical record indicated she was admitted to the facility on June 22, 2023, with diagnoses which included of schizophrenia, chronic pain syndrome, anxiety disorder, and diabetes mellitus type 2. Patient 8’s “History and Physical,” dated June 22, 2023, indicated the patient had the capacity to make decisions. A review of Patient 9’s medical record indicated the patient was admitted to the facility on September 24, 2022, with diagnoses which included dementia, anxiety, major depression, and chronic pain. A review of Patient 9’s “History and Physical,” dated September 29, 2022, did not indicate if patient had the capacity to make decisions. On August 15, 2023, at 3:52 p.m., an interview was conducted with the Social Services Assistant (SSA). The SSA stated the facility Administrator and staff conducted a consented room search for Patient 3, Patient 8, and Patient 9. The law enforcement confiscated the drugs and paraphernalia; and tested the substances to see what kind of drugs the patient had. The SSA stated on August 2, 2023, Patient 2 willingly opened the drawer and surrendered liquid speed (methamphetamine) in syringes (a medical device with a needle attached to a hollow cylinder that is fitted with a sliding plunger used to inject fluid into the body). The SSA stated on August 11, 2023, the facility did room searches with law enforcement present for Patient 1, Patient 2, Patient 4, and Patient 5. The SSA stated they found drugs, and drug paraphernalia. The SSA stated the law enforcement confiscated the drugs and paraphernalia; and tested the substances to see what kind of drugs they had. On August 15, 2023, at 4:25 p.m., an interview was conducted with the facility Administrator (ADM). The ADM stated the law enforcement have been coming out all week to confiscate the drugs and paraphernalia they found in patient rooms. The ADM stated that the Director of Nursing (DON 1) was notified that Patient 1 was receiving drugs through his room window and had distributed the drugs to certain patients. The ADM stated the room searches were consented and were done on two separate occasions in the presence of the law enforcement, on August 2 and on August 11, 2023. On August 15, 2023, at 5:45 p.m., an interview was conducted with Patient 1. Patient 1 stated he consented to the room search on August 11, 2023. Patient 1 stated the police were there, but the staff did the search. Patient 1 stated the staff found a pipe that was not his. Patient 1 stated the police were there and did not do anything. On August 21, 2023, at 1:09 p.m., an interview was conducted with the Director of Nursing (DON 1). DON 1 stated on August 2, 2023, he got a report from staff that there were drugs in the facility. DON 1 stated they got patients' (Patients 1, 2, 3, 4, 5, 8, and 9) consent to search the rooms, and when they found drugs, the law enforcement confiscated the drugs. On August 21, 2023, at 1:50 p.m., an interview was conducted with Patient 2. Patient 2 stated her room was not searched; and the patient stated the illegal drugs were sitting out on her (Patient 2) nightstand drawer, Patient 2 stated she was not offered substance abuse counseling, and that she was independent and did things for herself and did not require supervision. On August 30, 2023, at 12:08 p.m., observed that Patient 1 was not in his room, or in the facility. On August 30, 2023, at 12:11 p.m., an interview was conducted with CNA 6. CNA 6 stated she was assigned to Patient 1. CNA 6 stated she was not sure where Patient 1 was at this time. CNA 6 stated Patient 1 might be out on pass or at an appointment. CNA 6 stated she last saw Patient 1 at the smoking patio while she was passing breakfast trays. On August 30, 2023, at 12:39 p.m., an interview was conducted with Licensed Vocational Nurse (LVN 4). LVN 4 stated she had not been provided in-service regarding patients doing illegal drugs. A review of patient 1’s “IDT-Meeting,” dated August 11, 2023, at 3:51 p.m., indicated, “SSA was notified by the DON that he had called law enforcement because patient (Patient 1) was seen passing drugs of some sort to another patient. And (sic) was notified that he sells drugs out of the window of his room. Patients room is adjacent to the street and smoking patio. Officer notified patient that his belongings were to be searched and patient agreed…Patient was previously spoken to on August 2, 2023, about possession of contraband in his room. IDT entered the room with the officer while the officer searched patient’s belongings and there was cracked filled pipes and marijuana in his possession. Patient stated he did not know where that come (sic) from. The officer stated (sic) 'I was standing here when they searched your things, and this was found in the black and grey bag that is in your possession' Patient denied that it was his. Patient stated he was leaving then heading out of the building and left without signing AMA or obtaining order from MD…” A review of Patient 2’s “IDT – Meeting,” dated August 2, 2023, at 1:53 p.m., indicated, “…she opened a pouch with a white substance, and liquid filled syringes...” Patient 2’s “Drug Screen, Urine” collected August 4, 2023, at 9 a.m., indicated positive results for amphetamine and opiates. Patient 2’s “IDT-Meeting,” dated August 11, 2023, at 4:12 p.m., indicated “…DON was notified that Patient was under the influence of some substance…DON, ADM, MDS, SSD, with police went to Patients’ room where there was liquid filled needle with methamphetamine also marijuana…" A review of Patient 3’s “IDT-Meeting” dated August 2, 2023, at 1:35 p.m., indicated “…DON was notified that Patient was distributing drugs throughout the faculty (sic)…DON asked Patient if he had drugs, he then started pulling things out of his drawer an (sic) it as Marijuana (sic) also Methamphetamine (sic) filled needles. DON asked who’s (sic), box was at the top of the closet he stated not mines (sic) inside the box there were several needles filled with liquid Methamphetamine Patient verbalized I don’t know were (sic) that came from patient appeared to be high not acting himself…" A review of Patient 3’s “CPAC – Nursing – SBAR, (Situation, Background, Assessment, Recommendation), Communication Form and progress note,” dated August 3, 2023, at 3:19 p.m., indicated “…Suspected drug use due to substance found in room…At approximately 1500, IDT team began to search res room, (sic) Upon search, IDT team found powdered substance, liquid filled needles, powder meth, and PCP. Illegal substances and drug paraphernalia was (sic) confiscated. MD made aware…” A review of Patient 3’s “Drug Screen Panel, Urine," indicated the following: a. On August 3, 2023, at 6 p.m., was positive for amphetamines, opiates, and cannabinoids. b. On August 25, 2023, at 4:20 a.m., was positive for amphetamines, opiates, and cannabinoids. A review of Patient 3’s “Progress Notes,” dated August 27, 2023, at 6:20 p.m., indicated “Patient appeared to be under the influence, speech was garbled, pale in color, noted to be laying in the bed half on the ground, unresponsive to verbal stimuli or touch…” A review of Patient 4’s “IDT Meeting,” dated August 11, 2023, at 4:06 p.m., indicated “…DON was notified there was drugs being distributed from patient room. IDT entered patient’s room after police was (sic) called. Patient was found to have marijuana, also white powdered substance in a plastic bag, as well as crack pipes and marijuana filled vapes (sic) Patient was advised of the facility policy and that he was out of compliance (sic) Patient also verbalized he would like to go to a lower level of care (sic) SSD assured him that he would be places (sic) as soon as possible. Patient is alert and able to make needs known…” Patient 4 had no orders for a drug screen and no documentation indicating supervision of daily activities were conducted. A review of Patient 5’s “IDT Meeting,” dated August 11, 2023, at 4:14 p.m., indicated “… 8/11/23 “…DON was notified there was suspicion of drugs in patients (sic) room. IDT met with patients room it was found that patient was in possession of a sock full (sic) methadone ready to be distributed, also marijuana, and crack pipe with substance inside also liquor…Patient verbalized that it was wrong and that he would not do it again…” A review of Patient 8’s “IDT – Meeting,” dated August 4, 2023, at 3:10 p.m., indicated, “IDT met with patient in regard to closing her door. Notified (sic) patient the door is to remain open due to recent noted substance use/ (sic) and having illegal substances while staying at facility. Patient (sic) verbalized understanding…” A review of Patient 8’s “Drug Screen – Urine,” collected on August 8, 2023, at 9 p.m., was positive for amphetamines. A review of Patient 9’s “SBAR Communication Form and progress note,” dated August 2, 2023, at 3 p.m., indicated “…IDT team began to search res. (resident) Room. Upon search, IDT team found a powder substance and liquid filled needles. Illegal substances and drug paraphernalia was confiscated. MD (medical doctor) made aware…” A review of Patient 9’s “Progress Notes,” dated August 13, 2023, at 5:54 p.m., indicated “Patient noted to be possibly under the influence of a substance. Patient speaking erratically, pupils dilated…” A review of Patient 9’s “Progress Notes,” dated August 28, 2023, at 5:45 p.m., indicated, “Approx 1725 while on med pass, CN (charge nurse) received a page from IP (Infection Preventionist) to station one. On getting there the CN noted res (resident) on EMT(Emergency Medical Technician) gurney…Res noted with deviation from baseline, disoriented, and appears to be possibly under the influence of unknown substance…” A review of Patient 9’s “Progress Notes,” dated August 28, 2023, at 11:40 p.m., indicated, “…received by RN…via (name of hospital) …was seen for AMS (altered mental status), urine drug screen performed-positive for amphetamines and opiates…” A review of Patients 1, 2, 3, 4, 5, 8, and 9's records had no documentation indicating supervision of daily activities were conducted. A review of the facility’s policy and procedure titled, "Safety and Supervision of Patients,” dated January, 2018, indicated “…Our facility-oriented approach to safety addresses risks for groups of Patients…Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes…The Interdisciplinary care team shall analyze information obtained from assessments, and observations to identify any specific…risks for individual Patients…The care team shall target interventions for individual Patients related to hazards in the environment, including adequate supervision…” A review of the facility’s policy and procedure titled, “Patient Drug & Alcohol Abuse,” undated, indicated, “…To Provide a safe and drug-free environment for Patients while at the facility…The Facility has a zero-tolerance policy for the u