F0689

G

Failure to Supervise High-Risk Visitor Resulting in Resident Overdose Event

Paramount, California Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own “Safety and Supervision of Residents” policy regarding a visitor known to pose a safety risk. Resident 1, who had diagnoses including psychoactive substance abuse, respiratory failure, chronic kidney disease, ventilator dependence, and a gastrostomy tube, had a documented history at a previous facility of suspected illicit substance provision by Family Member (FM) 2. Progress notes from the prior facility dated 10/15/2025, 11/2/2025, and 11/3/2025 documented episodes of altered mental status occurring only during FM 2’s visits, suspected drugs provided by FM 2, and a positive urine drug screen for barbiturates suspected to have been provided by FM 2. An IDT note dated 11/7/2025 indicated FM 2 had been placed on supervised visits at the previous facility due to these concerns.

At the current facility, concerns about FM 2 continued. A respiratory therapy note dated 1/30/2026 documented that FM 1 expressed not trusting FM 2 and believed FM 2 was giving Resident 1 something that could affect breathing. Another RT note dated 2/5/2026 described that after FM 2 left, Resident 1’s ventilator alarmed, Resident 1 had an altered level of consciousness, and was breathing at a rate of four breaths per minute, later becoming more arousable after aggressive stimulation. A physician progress note dated 2/26/2026 indicated suspicion that Resident 1 may have been using drugs other than those prescribed due to altered mental status. LVN 1 reported that FM 2 had been placed on supervised visits because he brought drinks to Resident 1 despite NPO status, and on 1/14/2026 LVN 1 observed a beer in a clear bag brought in by FM 2. LVN 1 stated FM 2’s visits were to be supervised only by facility staff to prevent unauthorized items being provided.

Despite this history and the facility’s policy emphasizing resident safety and supervision as core components of accident prevention, the facility failed to ensure that FM 2 was not allowed to visit Resident 1 without staff supervision on 2/27/2026 and failed to ensure that facility staff, rather than FM 1, supervised FM 2’s visit. On that date, RT 1 responded to Resident 1’s ventilator alarm and found Resident 1 difficult to arouse, with suspected consumption of alcohol or drugs, and FM 1 told RT 1 that Resident 1 had consumed something. Resident 1 became unresponsive with hypoxia, bradypnea, and altered mental status, requiring emergency administration of Narcan and transfer to a general acute care hospital for evaluation and treatment. The DON acknowledged that facility staff, not FM 1, should have supervised FM 2’s bedside visit and that the incident could have been avoided if visitors had been supervised by staff, particularly given FM 2’s suspicious, agitated, and restless behavior at the time.