F0684

J

Failure to Assess and Respond to Resident Intoxication and Change in Condition Resulting in Death

Longmont, Colorado Survey Completed on 03-10-2026

Penalty

Fine: $53,550

Summary

The deficiency involves the facility’s failure to ensure that a resident with multiple complex medical conditions received treatment and care in accordance with professional standards of practice following a clear change in condition related to alcohol intoxication. The resident had diagnoses including alcoholic polyneuropathy, history of traumatic brain injury, CHF, type 2 diabetes mellitus, alcoholic cirrhosis of the liver, hypertension, long-term anticoagulant use, and alcohol use with an unspecified alcohol-induced disorder. His MDS showed severe cognitive impairment and functional dependence for many ADLs, though he typically ambulated without a mobility device. Physician orders included monitoring for potential substance use each shift and documenting and notifying the physician if any substance use indicators were noted, but the January TAR documented no substance use behaviors for that month.

On the day of the incident, the resident signed out of the facility in the morning and was later found outside the facility grounds by bystanders, yelling for help and lying on the ground near a hotel with a shopping cart. Police dispatch records show multiple calls reporting the resident on the ground and yelling for help, and the police ultimately identified him and returned him to the facility. The police reported to staff that the resident was intoxicated and had been wandering. Upon return, he required wheelchair transport from the front door to his room, despite normally walking without assistive devices. According to an IDT note, officers assisted him in removing his shoes and coat and helped him into bed, after which he was observed resting in his room, but no time or assessment details were documented.

Record review revealed no documentation that nursing staff completed a change of condition assessment, a post-fall or post-ground-level event assessment, or any RN assessment when the resident was returned by police in an intoxicated state. There was no documentation of vital signs, head-to-toe assessment, skin evaluation, or monitoring between the time of his return and the time he was later found unresponsive. The physician and the resident’s legal guardian were not notified of his intoxication or change in condition, and there was no progress note describing his condition upon return or how he was transferred to bed. The resident’s comprehensive care plan contained no care plan addressing alcohol use, intoxication, or potential substance use, and there were no interventions related to his known history of alcohol abuse and drinking while away from the facility. Staff interviews, including with the DON/acting NHA, ADON, and RNs, confirmed that no change of condition assessment, vital signs, or physician/guardian notifications were completed despite their own descriptions of what should occur when a resident returns intoxicated. The resident was later found face down on the floor in his room, unresponsive, and was pronounced dead; his death certificate listed respiratory failure, aspiration event, and alcoholism as the causes of death.

The facility also failed to promptly recognize and investigate the incident as an unexpected death associated with a significant change in condition. A frequent visitor reported that the DON/acting NHA initially did not believe an occurrence report was required for the resident’s intoxicated return and unexpected death, and the occurrence report to the state was not submitted until eight days after the death. There was no evidence of an immediate, thorough internal investigation or root cause analysis at the time of the event to determine why nurses did not complete a change in condition assessment or follow the existing physician order to monitor for substance use and notify the physician. Surveyors determined that the facility did not thoroughly assess and monitor the resident’s alcohol use and change in condition, did not document changes, and did not seek medical treatment or notify the physician and guardian when required, and that these failures contributed to serious harm and death for the resident.

Removal Plan

• NHA notified the facility medical director of the incident.
• Nursing supervisors/designees completed physical assessments/interviews on all residents to identify any changes in condition and notified the physician of any noted changes.
• Initiated a look-back audit of current and discharged residents to ensure change-of-condition policy was followed.
• Identified one current resident without a required 72-hour alert monitoring order; educated the assigned nurse regarding timely initiation of the 72-hour alert monitoring order after completing the eINTERACT change-in-condition evaluation.
• Initiated the missing 72-hour change-in-condition alert monitoring order for the identified resident, including nursing assessments and documentation on the TAR and in progress notes each shift for three days per physician-indicated frequency.
• Reviewed resident change-in-condition and notification policies/procedures for clinical accuracy.
• Educated all nursing staff on addressing changes of condition (assessment, monitoring, physician/family notification, orders, and facility policies/procedures); staff were not permitted to work a shift until education was completed.
• Educated new hires (licensed nurses and nurse aides) during orientation on change-of-condition and physician/family notification requirements and facility policies/procedures.
• DON/designee to conduct audits five times per week for three months of the 24-hour report and progress note report to ensure change-of-condition policies/procedures are followed.
• DON/designee to conduct daily nursing staff huddles Monday through Friday to monitor for changes in resident condition.
• Regional director of clinical services and regional vice president to provide clinical/administrative oversight to ensure education and audits are completed and accurate.
• DON educated by the CNO on appropriately addressing changes of condition (assessment, monitoring, physician orders, and facility policies/procedures).
• DON/designee to complete chart audits to verify detailed assessments/documentation and physician/family notification related to changes of condition.
• Regional Director of Clinical Services to visit the facility to provide general oversight and monitoring of the plan.