Health inspection·November 16, 2023

F689 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: • Identifying hazard(s) and risk(s). • Evaluating and analyzing hazard(s) and risk(s). • Implementing interventions to reduce hazard(s) and risk(s); and • Monitoring for effectiveness and modifying interventions when necessary. § 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. On 10/2/2023 the California Department of Public Health (CDPH) received a complaint alleging the facility did not investigate and report an unusual occurrence and did not complete an assessment and monitor a resident who was suspected of using an illicit drug while at the facility. On 10/4/2023 at 8:50 a.m., an unannounced visit was made to the facility to investigate the complaint on Resident 4 supervision and prevention of and/or risks of hazards and accidents. It was determined the facility did not investigate and report the unusual occurrence to CDPH. The facility staff did not initiate an assessment and monitoring of Resident 4's suspected of using an illicit drug while at the facility. The facility failed to: 1.Ensure Resident 4 was prevented from procuring (an effort of getting something) and using illicit (addictive and illegal) drugs. 2. Ensure Resident 4 was assessed, monitored, and educated about adverse interaction and adverse effects of amphetamine (central nervous system stimulant that causes hypertension, increased heart rate with increased feelings of energy) and other illicit drugs. 3. Ensure Resident 4's primary care physician (PCP) was informed of Resident 4's possible use of illicit drugs on 9/18/2023. 4. Implement the facility's Policy and Procedure (P/P) on "Resident Possession and Use of Illegal Substances" dated 12/19/22, by determining how Resident 4 have gained access to illegal substance brought into the facility. 5. Report the allegation of use of illicit drugs with paraphernalia in the facility to the CDPH, and local law enforcement. These failures had the potential to cause serious harm to Resident 4 and other residents' residing in the facility and a causative factor in Resident 4 complaining of headache, left sided chest pain, weakness, high blood pressure of 227/121 millimeters of mercury ([mmHg] high blood pressure is greater than 140/90) and was transferred to General Acute Care Hospital (GACH) via 911 on 9/21/2023. A review, Resident 4's Admission Records indicated Resident 4, a 56 years old male, was admitted to the facility on 9/1/2023 with diagnoses that included low back pain, hypertension (blood pressure higher than normal), end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids in a permanent basis), dependence on renal dialysis (dependent on a machine used to filter and clean the blood to remove harmful substances from the body) and major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest and can interfere with one's day to day activities). A review of Resident 4's Minimum Data Set ([MDS] assessment, a care plan and screening tool), dated 9/7/2023, indicated Resident 4 had intact cognitive (ability to learn, remember, understand, and make decision) ability for daily decision making, and able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 4 requires extensive one-person physical assist to complete his activities of daily living (ADLs) task such as bed mobility, transfer, and dressing. A review, Resident 4's Change of Condition Form (COC), dated 9/21/2023 timed at 4:35 p.m., indicated Resident 4 was transferred to a GACH due to Resident 4 complaining of headache, left sided chest pain with a pain level of 5/10 (pain scale with 0 as no pain and 10 as worst possible pain), weakness, and high blood pressure of 227/121 mmHg. Resident 4 received hemodialysis on 9/20/2023. A review, Resident 4's GACH discharge summary dated 9/22/2023, emergency visit on 9/21/2023 the discharge summary indicated Resident 4 was admitted with chest pain, hypertension, and elevated B-type Natriuretic peptide (BNP- blood test indicating the heart must work harder to pump blood, this test was important tool for the physician to diagnose heart failure quickly). The discharge summary indicated that Resident 4 blood pressure upon discharge from GACH was 144/83 mmHg which was still above the reference range (120/80 mmHg-140/90mmHg). A review of Resident 4's Laboratory Results Report collected 9/28/2023 at 6:30 a.m. and reported on 10/5/2023 at 6:04 p.m., the Lab Results Report indicated Resident 4 tested positive for amphetamine (central nervous system stimulant that causes hypertension, increased heart rate with increased feelings of energy) through a urine drug screen done in the facility. During an interview on 10/4/2023 at 4:22 p.m., Resident 4 stated he has been using drugs (crystal meth [the drug methamphetamine in a powdered crystalline form] and amphetamine) for years now. Resident 4 stated the last time he used illicit drugs was two weeks ago (9/18/23). Resident 4 stated it happened inside his room early in the morning. Resident 4 stated he was holding the glass pipe (paraphernalia) when he lit it, it suddenly got hot and he dropped the glass pipe on the floor, causing it to break. Resident 4 stated no one saw him when he lit the glass pipe and dropped it on the floor. Resident 4 stated he thought he picked up the broken glass pieces from the floor. Resident 4 stated facility staff did not ask him if his belongings could be checked in his room when he returned from dialysis and when he returned from an out on pass. Resident 4 further stated that no facility staff discussed with him the policy of illicit drug use in the facility. Resident 4 stated that no education has been provided to him about the health and safety risks associated with using illicit drugs in the facility. Resident 4 expressed concerns that this lack of information could potentially compromise the safety and well-being of himself, other residents residing in the facility and facility staff. During an interview on 10/4/2023 at 1:54 p.m., the Housekeeper (HK) 1, HK 1 stated that on 9/18/2023 during the 7:00 a.m. to 3:00 p.m. shift, she found some crystal-like particles on the floor of Resident 4's room. These particles looked like thin broken glass and were found in a towel next to Resident 4's bed. HK 1 stated she noticed a broken glass pipe that appeared burnt and had black substance residue on it. HK 1 stated she promptly informed the charge nurse (LVN 3) about her findings. During an interview on 10/4/2023 at 12:16 p.m., Licensed Vocational Nurse (LVN) 2, stated HK 1 informed LVN 3 about the broken pipe wrap in a towel in Resident 4's room on 9/18/23. LVN 2 and LVN 3, had a meeting with the Director of Nursing (DON) and the Administrator (ADM) at the nursing station. LVN 2 stated the DON stated this incident of suspected illicit drug use was not reportable because the facility was just "assuming." LVN 2 expressed concern about the potential impact of suspected illicit drug use on the health and safety of Resident 4, other residents, and staff as there was no guidance from the DON and Administrator. LVN 2 stated Resident 4 was not assessed and monitored after the incident. During a telephone interview on 10/4/2023 at 2:52 p.m., Licensed Vocational Nurse 3 (LVN 3) stated on 9/18/2023, HK 1 gave her what she found on Resident 4's room. LVN 3 stated she placed the items (broken glass pipe and broken glass like substances with black residue) inside a zip lock bag and gave it to the DON. LVN 3 stated per DON's instruction not to do a change of condition assessment, document the incident on the nursing progress notes and initiate a care plan. LVN 3 stated Resident 4's physician was not informed of the incident on 9/18/2023. She further stated Administrator told her to "just monitor" Resident 4. A review of Resident 4's complete medical record, the medical record indicated there was no documentation to demonstrate the facility staff monitored, assessed for signs and symptoms of amphetamine adverse effect and possible interaction with other medication nor educated Resident 4 of amphetamine adverse effects. During a telephone interview on 10/5/2023 at 11:00 a.m., Resident 4's primary care physician (PCP), stated he was aware of Resident 4's suspected use of (amphetamines) crystal meth. PCP stated facility's staff informed him of suspicion that Resident 4 was using illicit drug (cannot remember the exact date). The PCP stated he gave an order for urine drug toxicology (test that checks for drugs or other chemicals in your urine) or blood toxicology (a test that checks for drugs or other chemicals in the blood) as Resident 4 was anuric (does not produce urine). The PCP stated he was concerned of Resident 4's adverse drug interactions (unintended, harmful events attributed to the use of medicines) if he uses illicit drugs in combination with his other medications. Another concern regarding the use of illicit drugs like crystal meth would be for Resident 4, who has a diagnosis of End Stage Renal Disease (ESRD-a medical condition in which a person's kidneys cease functioning on a permanent basis), could lead to a change in his condition, including severe high blood pressure (hypertensive crisis- blood pressure reading is 180/120 millimeters of mercury (mm Hg) or greater, this would be detrimental to Resident 4's health and overall wellbeing. During an interview on 10/5/2023 at 4:19 p.m., Registered Nurse Supervisor (RNS) 2, stated Resident 4 was transferred to GACH on 9/21/2023 due to complaining of chest pain, rated as a 5 (moderate level of pain) on the pain scale and high blood pressure of 227/121 mm Hg. RNS 2 stated that if there was any suspicion of illicit drug used, she (RNS 2) will gather the evidence and secure it, as it can be used for investigation by law enforcement agencies. RNS 2 stated that the use of illicit drugs in the facility poses a health and safety risk to other residents, staff, and visitors because a resident using illicit drugs can change their behavior, potentially affecting the safety of everyone in the facility. RNS 2 stated licensed nurses were expected to contact the physician to inform the physician of the Resident 4's condition, to obtain orders, referrals, and other necessary treatments. RNS 2 stated licensed nurses should initiate a change of condition process to ensure continuous assessment and monitoring were provided to Resident 4. Additionally, body checks should have been conducted when Resident 4 returned to the facility from dialysis, out on pass, and other appointments. During an interview on 10/5/2023 at 1:59 pm, the DON stated there was no investigation conducted by either her or the Administrator after LVN 2 and LVN 3 informed them about what was found in Resident 4's room by HK 1 (the glass like particles on the floor and broken glass pipe that appeared burnt and had a black substance residue). The DON stated Resident 4's physician was not notified of the incident and no in-services were done with the licensed nurses regarding the facility's policy on "Resident Possession and Use of Illegal Substances." During an interview on 10/6/2023 at 9:44 a.m., the Social Services Director (SSD), the SSD stated she was not notified of Resident 4's suspected illicit drug use in the facility. SSD stated there was no interdisciplinary care plan meeting (care team gathers to review the plan of care for a resident.), social services reassessment, and psychologist (a person who specializes in the study of mind and behavior) referral for Resident 4. The SSD stated this unusual occurrence was not immediately reported to the local law enforcement, Ombudsman, and the State Agency (California Department of Public Health). The SSD stated this incident (suspicion of illicit drug used) was alarming because the potential actions of a suspected illicit drug user while under the influence of illicit drugs were unknown. This uncertainty raises concerns about the potential impact on the residents and staff within the facility. During an interview on 10/6/2023 at 10:42 a.m. the Minimum Data Set Nurse (MDSN), stated Resident 4 could potentially experience adverse drug interactions if he uses illicit drugs in combination with his other medications. The MDSN stated that illicit drugs are strong stimulants (substances that speed up the body's functions) and can cause multiple side effects (increased blood pressure, irregular heart rate and increased breathing). The MDSN stated that the facility should have investigated the incident to determine if the incident (suspicion of illicit drug use) really occurred or not. MDSN stated it was the responsibility of the facility to prioritize the safety of Resident 4 and other residents by acknowledging the situation and taking appropriate action. During an interview on 10/6/2023 at 11:26 a.m., the Administrator (ADM) stated the incident with Resident 4 (found broken glass pipe that appeared burnt and had black substance residue) should have been thoroughly investigated. The ADM stated the facility does not tolerate illicit drug use in the facility. The ADM stated there was no investigation conducted by the facility after LVN 2 and LVN 3 reported the incident to him regarding HK 1 finding a broken glass pipe that appeared burnt and had black substance residue in resident 4's room. https://www.dea.gov/factsheets/methamphetamine According to the United States Department of Justice Drug Enforcement Administration Drug Fact Sheet (DFS) on Methamphetamine (central nervous system stimulant that causes hypertension, increased heart rate with increased feelings of energy) dated 10/2022, the DFS indicated methamphetamine is a Schedule II stimulant (substances, or chemicals are defined as drugs with a high potential for abuse) under the Controlled Substances Act...Methamphetamine comes in a pill or powder form and Crystal Meth resembles glass fragments or shiny blue, white "rocks" of various sizes and such drug can be swallowed, snorted, injected, or smoked. Chronic meth users can exhibit violent behavior, anxiety, confusion, insomnia (sleeplessness) and psychotic (symptoms that affect the mind, where there is loss of contact with reality) features including paranoia (unjustified suspicion and mistrust), aggression, visual and auditory hallucinations (experience involving the apparent perception of something not present), and delusions (a false belief or judgement about external reality)- such as sensation of insects creeping on or under the skin and such paranoia can result in homicidal (capable of or tending towards murder) or suicidal (likely to have damaging effect on oneself or one's interests) thoughts. Taking small amounts of methamphetamine can result in increased wakefulness, increased physical activity, decreased appetite, rapid breathing and heart rate, irregular heartbeat, increased blood pressure and hyperthermia (a body temperature greater than normal) which can cause convulsions ( a sudden, violent irregular movement of a part of the body or of the body due to the presence of certain toxins/agents/substances in the blood, cardiovascular collapse (collapse, no pulse, no breathing, loss of consciousness), and death. High doses may result in death from stroke, heart attack or multiple organ problems caused by overheating. A review of the facility's P/P titled, "Unusual Occurrence" revised 12/19/2022, the P/P indicated it is the policy of the facility t