Failure to Supervise Residents with Substance Use Disorders
Summary
The facility failed to properly identify potential risks and hazards for residents with a substance use disorder and provide adequate supervision to prevent drug overdoses. This deficiency resulted in Immediate Jeopardy and actual harm when a resident with a known substance abuse history was found unresponsive and required cardiopulmonary resuscitation (CPR) and hospitalization after a Fentanyl and Methadone overdose. Another resident with a known substance abuse history was also found unresponsive and required CPR after a drug overdose. The facility had identified 15 residents with active or current substance use disorders, ten residents with behavioral health needs, and 14 residents who participated in the facility's substance abuse program. The incidents occurred because the facility did not enforce its visitation policy, which required supervised visits for residents in the substance abuse program. On multiple occasions, residents were found unresponsive due to drug overdoses after unsupervised visits. The facility's failure to supervise these visits allowed residents to obtain and use drugs, leading to life-threatening situations. Interviews with staff revealed that the facility's substance use disorder program was not adequately enforced, and visits were not supervised as required by the facility's policy. The facility's assessment and care plans for the residents involved indicated that they had mood and behavior problems related to substance abuse and required specific interventions, including supervised visits and participation in a third-party substance abuse program. However, these interventions were not consistently implemented, leading to the overdoses. The facility's failure to conduct adequate room searches and monitor residents' conditions further contributed to the incidents. The deficiency was identified and corrected after the survey, but the lack of proper supervision and enforcement of the facility's policies led to significant harm to the residents involved.
Removal Plan
- Licensed Practical Nurse (LPN) #223 called 911 related to Resident #44.
- The Director of Nursing (DON) was notified by LPN #216 of a possible overdose of Resident #44.
- Akron City Emergency Medical Services (EMS) arrived at the facility, administered Resident #44 Narcan. MD #800 was notified, orders to monitor resident and complete tox screen. LPN #223 was asked by LPN #216 to witness an interview with Resident #61 about an incident that occurred with Resident #44. When both nurses approached Resident #61's room, they observed the resident lying face down on his floor and unresponsive. LPN #223 initiated CPR and LPN #216 went to the third floor to alert the paramedics that were already in the building.
- DON was notified by LPN #223 that Resident #61 was found unresponsive of possibly an overdose.
- The DON advised charge nurses LPN #223 and LPN #216 to complete a head count of residents and check the status of all residents. All other residents were accounted for with no concerns.
- Charge nurses LPN #223 and LPN #216 were directed to obtain statements from all staff in the building regarding the incident.
- The DON notified the Administrator two residents (#44 and #61) were found unresponsive from a possible drug overdose.
- LPN #223 notified MD #800 of Resident #61 being unresponsive.
- The DON arrived at the facility. A whole house audit was completed to ensure no other residents had been affected. The DON went to Resident #61's room to check his status. Then, DON went to the third floor to check the status of Resident #44.
- Resident #44 and Resident #61 were placed on Q 15-minute safety checks.
- The Administrator arrived at the facility.
- LPN #223 received an order from MD #800 to complete urinalysis from both residents (#44 and #61).
- The Administrator reviewed and made a copy of the visitor log with the findings of a visitor for Resident #44.
- The DON received a call from nurse LPN #223 for a change in condition for Resident #44. MD #800 was notified and 911 was called and Resident #44 was transferred to the hospital.
- RDCS #700, the Administrator and the DON reviewed staff statements, and staffing list for current day. It was determined the root cause of the drug overdose incident was a facility failure to supervise visitation per the facility substance abuse program policy.
- Education on the facility substance abuse program interventions and monitoring was initiated by the Administrator and DON for all facility staff.
- The third-party program residents were provided with their signed contracts in order to review the expectations of the contract by SS #276, the counselor from the program.
- A Quality Assessment Performance Improvement (QAPI) meeting was held with RDO #710 and MD #800 via telephone, RDCS #700, the Administrator, DON, Unit Manager/LPN #201, Medical Records (MR) #204, Admissions Director (AD) #205, Business Office Manager (BOM) #202, Human Resources (HR) #203, and Therapy Director (DOR) #720, to discuss the incidents.
- Resident #44 returned to the facility and agreed to participate in individual and case management services through the third-party program. Resident #44 had participated in the third-party program and then again began participation.
- LPN #216 notified the DON of concern for Resident #61 appearing under the influence due to resident being difficult to arouse and not acting like self. The nurse then called MD #800 and EMS to transport the resident to the hospital. EMS arrived at the facility with police due to concern of possible overdose. Staff at the facility searched Resident #61's room with police officers. Inside his notebook a folded-up bus pass was located with a black substance in it. Officers tested the substance which was positive for Fentanyl.
- Resident #61 returned to the facility after testing positive for Fentanyl in hospital.
- The facility clinical team met with SS #276 to discuss the incident that occurred involving Resident #61.
- The Administrator held a QAPI meeting to discuss the root cause of the incident and determined facility failure to conduct adequate room searches. Staff in attendance at the QAPI meeting included RDO #710 and MD #800 via telephone, RDCS #700, the Administrator, the DON, Unit Managers LPN #201 and LPN #200, MR #204, AD #205, BOM #202, HR #203, and DOR #720.
- The Administrator and RDO #710 completed room searches for all residents in the substance use disorder program with no additional negative findings. Residents were observed at this time for any changes in behaviors such as slurring of words, change in cognition, increase in agitation and avoidance of eye contact or conversation. No concerns noted at this time.
- Resident #61 discharged from the facility. The resident was given discharge instructions and summary. MD #800 was in agreement with the resident's discharge.
- RDO #710 educated the department head team which included the Administrator, the DON, Unit Managers LPN #200 and LPN #201, MR #204, AD #205, BOM #202, HR #203 and DOR #720 on the facility's substance abuse disorder program policy with emphasis on random room searches, random search of any delivered packages and supervised visitation.
- Department head (BOM #202, DON, the Administrator, HR #203, AD #205, Unit Manager/LPN #201, MR #204, Activities Director (AD) #208, and Minimum Data Set nurse (MDS) #207) education was provided regarding the substance abuse contract completed by RDO #710.
- All staff education was completed regarding the substance abuse contract by the department heads BOM #202, DON, the Administrator, HR #203, AD #205, Unit Manager/LPN #201, MR #204, AD #208 and MDS #207.
- Front desk staff receptionist (RCP) #265, RCP #266 and RCP #267 were re-educated on the process of supervised visitation by the Administrator: 1. Visitation would be conducted in the main lobby and would be supervised by the receptionist or designee. 2. In the event the phone rings during a visit, the phones would not be answered by the receptionist and would roll over to the floors. 3. If assistance was needed, notify another staff member. 4. In the event of needing to leave the desk notify another staff member to cover.
- At least once a week the administrator and clinical team meet with SS #276, the third-party counselor, on Wednesdays and as needed. During this meeting a discussion of all residents who were active with attending groups through third-party program. Discussion of the residents, discharge plans, meeting goals, progress, or any concerns such as decreased participation, changes in behaviors or at risk. The bed board was present to discuss any residents who were not active in the program for reassessment and encouragement to participate. At the time of this meeting, it would be discussed for room searches and random tox screens to be completed with the third-party program and at the facility level. Communication between the Administrator and the third-party program/counselor would be continuous and as needed if any concerns arise.
- The facility implemented a plan for the Administrator/designee to audit the visitation log, to include monitoring of the sign in book for completion and to ensure visitations five times per week for four weeks and then randomly thereafter. Discrepancies would be reviewed in QAPI and revised as needed.
- The facility implemented a plan for the Administrator/designee to audit to ensure random room searches of residents participating in the substance use disorder program were completed for three residents weekly for four weeks and then randomly thereafter. All audit findings would be submitted to QAPI for recommendations and review.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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