Failure to Restrict and Monitor Visitor Access for Resident With Ongoing Substance Use Incidents
Summary
The deficiency involves the facility’s failure to implement and monitor its visitation and substance use disorder policies for a resident with a known history of psychoactive substance abuse and prior fentanyl overdose. The resident, who was cognitively intact but dependent on staff for transfers and with impaired mobility, had an active care plan for substance use that called for monitoring for signs and symptoms of substance use and abuse, such as confusion, drowsiness, outbursts of anger, and mood changes. Despite this, there was no documented evidence over multiple months that staff monitored the resident for these signs as outlined in the care plan. The facility’s visitation policy allowed for limiting or supervising visitors who abused, coerced, or exploited residents or who had a history of bringing illegal substances into the facility, but the facility did not operationalize these restrictions for this resident. Multiple documented incidents showed that the resident possessed or used substances and smoking materials, often in the presence of a specific family member visitor. On one occasion, staff observed the family member staying almost every night in the resident’s room and notified the DON and police due to suspicious behavior, but there was no documented investigation to determine the source of contraband. On another date, staff found the resident with vape devices and Blue Chew pills; these items were removed and given to a family member, and a late entry note by the DON recommended ongoing monitoring due to the resident’s substance-related history. However, there was no subsequent documentation that the resident was supervised or monitored for suspicious behaviors or signs of substance use as recommended. Later, staff documented that the resident’s room smelled like marijuana while the resident was with a visitor, and both were educated on facility policy, but the care plan was not revised to add new interventions related to this event. Further incidents continued without changes to visitation practices or documented monitoring. A restorative nursing assistant reported seeing the resident outside the facility with the same family member, who appeared to place an unknown smoking material to the resident’s mouth; this was reported to nursing and the administrator, and an order was obtained to closely monitor the resident for changes in level of consciousness, but there was no documentation that such monitoring occurred. Subsequently, the resident was found in his room vomiting, with foaming at the mouth and a smell of alcohol present; the family member at the bedside admitted giving the resident alcohol, and the resident was sent to the hospital and diagnosed with alcohol intoxication and alcohol abuse. When the resident returned from the hospital, there was no documentation that supervision or monitoring of the resident or the family member’s visits was implemented. Visitor sign-in records showed that the same family member and other friends continued to visit without restrictions or supervision. Interviews with the administrator, DON, nursing staff, and receptionist confirmed that no visitation restrictions or supervision were put in place for this family member, that there was no investigation into earlier contraband incidents, that the physician was not informed of key events, and that staff were not instructed on specific behaviors to monitor, despite the resident’s history and repeated episodes involving visitor-introduced substances.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A cognitively intact resident with multiple chronic conditions was denied her preferred visitor after an incident during a bible study activity. The Activities Mgr and ED spoke with the resident's son, who was not her POA, and the son approved telling the friend she could no longer visit; staff then informed the friend without telling the resident. The resident later said she still wanted the friend to visit, and the DON confirmed the son was only the advocate and emergency contact.
Restricted After-Hours Visitation: Staff interviews showed that a resident's family members were not allowed to enter after 8:00 p.m. because the doors were locked, despite facility policy stating that residents have the right to receive visitors of their choosing at the time of their choosing and that family members are not subject to visiting hour limits. The Assist ED later said family could still come in after hours by ringing the doorbell, but other staff said visits after 8:00 p.m. were not permitted except in limited situations.
Failure to Communicate Resident Visitation Restriction Request: A resident with dementia and no decision-making capacity had a family representative request that no visitors be allowed without the representative present. The BOM forwarded the request to the SSD, but the DON and other staff stated they were unaware of any visitation restriction, and the request was not documented or communicated to all staff as described in the report.
Restricted Visitation Hours: A posted sign and staff interviews showed that residents were limited to visiting hours from 8:00 a.m. to 8:00 p.m., and visitors arriving outside those times were turned away or told to return later. Two residents stated they did not like the limits and believed they should be able to decide when to receive visitors. The admission agreement also stated that residents have the right to visit anyone during visiting hours.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
Restricted visiting hours were posted at the entrance, stating visitors were only allowed during set times each day and on holidays. The Administrator said residents could have visitors at any time, but multiple residents said the posted hours matched current practice. An RCP stated the sign was placed on the door each evening, removed in the morning, and the front entrance was locked after 8:00 PM; a side doorbell was available, but there was no signage directing visitors to it.
Resident Visitor Preference Not Honored
Penalty
Summary
The facility failed to ensure a resident had the right to visitors according to her preference. Resident #17 was admitted with diagnoses including cerebral infarction due to embolism of an unspecified cerebral artery, COPD, morbid obesity due to excess calories, type 2 diabetes mellitus without complications, schizoaffective disorder, and polyneuropathy. Her quarterly MDS assessment identified her as cognitively intact, and she was her own responsible party. Interview and record review showed that after an incident involving Resident #17 and her friend during a facility bible study activity, multiple residents complained about the friend's behavior. The Activities Manager and Executive Director spoke with the resident's son, who did not know who the friend was, and he approved the facility contacting the friend to tell her she was no longer to visit Resident #17, while requesting staff not tell Resident #17 about the conversation. The Activities Manager confirmed she contacted the friend and informed her of the facility decision. Resident #17 later stated she wanted her friend to still be able to visit and that they could simply avoid bible study. The DON verified Resident #17 did not have a POA and that her son was her advocate and emergency contact. The facility policy stated it would provide reasonable access to a resident by any entity or individual, subject to the resident's right to deny or withdraw consent at any time.
Restricted After-Hours Visitation
Penalty
Summary
The facility failed to provide residents access to visitors of their choosing at the time of their choosing because it did not allow any visitors in the building after 8:00 p.m. Staff interviews showed that the doors were locked at 8:00 p.m., and family members were not permitted to enter after that time except for EMS personnel or family of a resident who was passing away. One LVN stated visitation hours were from 8:00 a.m. to 8:00 p.m. and that family members were not allowed in after 8:00 p.m. The receptionist gave the same account and said family visits after hours were only allowed for a resident who was care planned for a particular reason or if the resident was actively dying. A later interview with the Assist ED conflicted with the other staff statements, as he said the doors were locked at 8:00 p.m. for security reasons but family members were still allowed in whenever they wanted by ringing the doorbell and being let in by nursing staff. He also stated that staff were misinformed about visitation and that he was not sure where they got the information that family members were not allowed after 8:00 p.m. The facility policy stated that residents have the right to receive visitors of their choosing at the time of their choosing, that family members are not subject to visiting hour limitations, and that if visits infringe on other residents' rights, staff will find another location for the visit.
Failure to Communicate Resident Visitation Restriction Request
Penalty
Summary
The facility failed to ensure visitation restrictions were addressed for one resident when it was not aware of the resident representative’s request that the resident have no visitors without the representative’s presence. Resident 41 was admitted with diagnoses including ESRD, unspecified dementia, hyperlipidemia, anemia, pneumonia, and nicotine dependence. The resident’s H&P stated that the resident lacked capacity to make and understand decisions and identified a designated family representative. The resident’s MDS indicated the resident had adequate hearing, clear speech and vision, and required extensive assistance with bed mobility, transferring, toileting, and personal hygiene, with partial to moderate assistance with eating. A review of the resident representative’s email showed a request that Resident 41 not have any visitors without the representative present and that all CNAs and charge nurses be alerted. The BOM stated she immediately forwarded the email to the SSD, but the DON stated she had not seen the email and did not know of any residents with visiting restrictions. The SSD stated he verbally reported the request to the department head but could not elaborate further, and multiple staff members stated they were unaware of any visiting restrictions for the resident. The SSD later stated that visiting restriction requests needed to be communicated to the front desk and staff, and the DON stated the request should have been communicated to all staff.
Restricted Visitation Hours
Penalty
Summary
The facility failed to honor residents’ right to receive visitors of their choosing at the time of their choosing for 2 sampled residents. During observation, a sign posted above the double doors near the security desk stated, “Resident Visiting Hours 8:00 A.M. - 8:00 P.M.” During interview, one resident stated she did not like the limitations on visiting hours and believed she should be able to have visitors at a time she chose. Another resident stated the facility did not allow visitors outside the posted visiting hours and said she thought residents should be allowed to decide when they have visitors. Staff interviews confirmed the restriction. One staff member stated residents were not allowed to have visitors before 8:00 a.m. or after 8:00 p.m. Another staff member stated visiting hours were between 8:00 a.m. and 8:00 p.m., that visitors were not allowed outside those times, and that if visitors came outside visiting hours they would be told to come back during visiting hours. A third staff member stated the facility did not have a separate visitation policy and that the visiting hours were included in the admission agreement, which stated that all residents have the right to visit anyone during visiting hours.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Restricted Visiting Hours Posted at Entrance
Penalty
Summary
The facility failed to ensure residents were permitted to receive visitors at any time in accordance with resident rights by imposing facility-wide visiting hours. During observation, a sign taped to the glass entrance door stated that visiting hours had ended Monday through Sunday from 8:00 AM to 8:00 PM and on holidays from 9:00 AM to 5:00 PM, indicating restricted visitation outside those times. The Administrator stated residents are allowed visitors at any time and was unaware of the origin of the posted sign. Multiple residents later confirmed that the posted visiting hours reflected the facility's current visitation practice. The Receptionist stated she places the sign on the door each evening at 8:00 PM when she leaves and removes it upon her return at 8:00 AM, and that the front entrance door is locked after 8:00 PM. She also stated visitors would need to use a side doorbell to gain entry outside the posted hours, but there was no signage informing visitors of the doorbell.
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