Other·April 4, 2024

Title 22 72521©(6) § 72521. Administrative Policies and Procedures. (c) Each facility shall establish at least the following: (6) Procedures for reporting unusual occurrences F689 §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 An unannounced visit was conducted by California Department of Public Health (CDPH) on 2/20/24 to 2/23/24 for recertification survey. The facility failed to provide an environment that was safe and free from accident hazards, in accordance with the facility's policy and state regulation for Patient 1, when Patient 1 was found in possession of an illegal substance (drugs that a person is not allowed to own or use by law, such as methamphetamine) on 2/1/24. This deficient practice had the potential for other residents to have access to the illegal substance (drugs that a person is not allowed to own or use by law, such as methamphetamine) and place Patient 1 and other residents at risk for harm and hospitalization. A review of Patient 1 a 71 years old male's Admission Record indicated that Patient 1 was admitted to the facility on 10/24/23 with a diagnosis that included personal history of drug use and drug therapy. A review of Patient 1's History and Physical (H&P), dated 10/25/23, indicated Patient 1 had the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS, an assessment and care screening tool), dated 1/26/24, indicated Patient 1 had moderate cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS also indicated Patient 1 required substantial assistance (helper does more than half the effort) with toileting, hygiene, shower, upper and lower body dressing, putting on/taking off footwear, and personal hygiene and required partial assistance (helper does less than half the effort) with eating, and oral hygiene. A review of Patient 1's Nurses Progress Notes, dated 2/1/24, indicated Certified Nursing Assistant 7 (CNA 7) reportedly found an orange pill container in Patient 1's room under Patient 1's pillow. The progress notes also indicated, Patient 1 stated the substance inside the orange pill container was a methamphetamine (meth, a type of drug that lets residents stay awake and do continuous activity with less need for sleep) brought in by Patient 1’s family member who visited3 hours ago on 2/1/24. A review of the Urine Drug Test collected on 2/2/24 at 7 AM indicated Patient 1 was positive for Amphetamine (addictive, mood-altering drug, used illegally as a stimulant). During an interview on 2/23/24 at 9:50 AM, the Director of Nursing (DON) stated a crystal-like substance inside a pill bottle was found under Patient 1's pillow on 2/1/24. During an interview on 2/23/24 at 10 AM, the DON stated the drug was confiscated and was kept on a locked drawer in her office up to this date. The DON stated Patient 1 was assessed and observed to be drooling on the right side of his mouth while in his room on 2/1/24. The DON further stated she did not think the incident was reported to law enforcement and state survey agency. During an interview on 2/23/24 at 10:16 AM, the Administrator (ADM) stated the law enforcement was not and should have been notified of the illegal substance so the law enforcement could confiscate it. During an interview on 2/23/24 at 11:05 AM, the ADM stated the facility did not consider the incident as an unusual occurrence because the facility knew where the illegal substance came from. During an interview on 2/23/24 at 11:15 AM, the Social Services Director (SSD) stated she called the Patient 1's family member and admitted bringing the illegal substance to the facility. During an interview on 2/23/24 at 11:19 AM, the DON stated she did not remember to reach out to the pharmacist to obtain guidance on the proper way of disposing the illegal substance found in Patient 1's possession until just recently (2 days ago). The DON also stated the illegal substance found with Patient 1 was confiscated on 2/1/24 and was kept in a locked box in the DON's office. During an interview on 2/23/24 at 3:29 PM, Patient 1 stated he remembered the incident that happened (does not remember the date) when the facility staff found a pill container with an illegal substance found under his pillow but did not know who brought it. A review of the facility's policy and procedure titled, "Resident Drug and Alcohol Abuse," revised October 24, 2022, indicated its purpose was to provide a safe and drug free environment for residents while at the facility. The policy also indicated that the facility has a zero-tolerance policy for the use or possession of illegal drugs or any type of drug apparatus in the facility or on the grounds of the facility. The policy further indicated that a violation of the policy will result in notifications to the attending physician, responsible party, and law enforcement or state agencies as appropriate. A review of the facility's policy and procedure titled, "Unusual Occurrence Reporting," revised November 1, 2017, indicated its purpose was to ensure timely reports are made to designated agencies as required by state and federal law. The policy also indicated that the facility would follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrence. The policy further indicated that unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility failed to provide an environment that was safe and free from accident hazards, in accordance with the facility's policy and state regulation for Patient 1, when Patient 1 was found in possession of an illegal substance on 2/1/24. This deficient practice had the potential for other residents to have access to the illegal substance (drugs that a person is not allowed to own or use by law, such as methamphetamine) and place Patient 1 and other residents at risk for harm and hospitalization. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1 and other patients residing in the facility.