Highland Square Nursing And Rehabilitation

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A facility failed to protect a resident with moderate cognitive impairment from sexual abuse by a housekeeper. The housekeeper sent inappropriate text messages and photos to the resident, soliciting sexual favors, and subsequently engaged in sexual acts with the resident on two occasions. The resident reported performing these acts out of fear, and text message evidence corroborated the inappropriate communications initiated by the staff member. The resident's medical record indicated a history of traumatic brain injury, impaired cognition, and the presence of a legal guardian. The facility did not recognize the staff-to-resident sexual contact as abuse, despite the resident's cognitive impairment and the power imbalance between staff and resident. Interviews with facility leadership and staff revealed a belief that the relationship was consensual, and the facility's abuse policy at the time did not explicitly prohibit staff-resident intimate relationships or address the issue of consent in cognitively impaired residents. The facility's investigation concluded that the resident had willingly participated, and there was no intent to cause harm, despite statements from the resident and her guardian indicating fear and lack of true consent. The facility also failed to properly follow up with law enforcement regarding the incident. When the police were initially contacted, staff were unable to identify the perpetrator, and there was no subsequent update to the police once the staff member was identified. The facility did not implement additional interventions or follow-up in the resident's medical record after the incidents of sexual abuse were disclosed. The deficiency affected one resident out of three reviewed for abuse, in a facility with a census of 63.

Removal Plan

• Resident #50's friend updated facility staff that HK #208 came into Resident #50's room on two separate occasions in the previous week and made her perform oral sex on him.
• HK #208 was suspended pending further investigation.
• The facility opened a self-reported incident (SRI) tracking number 264268.
• HK #208's employment ended with the facility when the employee resigned.
• Resident #50 was signed up for psychological services with consent from her guardian and assistance from Social Services Designee (SSD) #212.
• Resident #50 was referred to follow-up with psychological services by Social Service Designee (SSD) #212 to evaluate mood status related to the incidents with HK #208.
• The social services designee completed a depression test, Patient Health Questionnaire-9 (PHQ-9), to evaluate the resident's mood status related to the incidents with the staff member.
• The President of Operations and President of Clinical Services educated the RDO #201 on BIMs assessment and scoring, staff to resident relations (as included in updated facility abuse policy deeming this act abuse), police follow-up, and thorough investigations.
• The President of Clinical Services updated the facility Abuse Policy to include staff to resident relations, specifically in the policy training section.
• The facility re-opened the SRI related to Resident #50. The police were updated that Resident #50 wanted to re-speak with them again.
• The RDO #201 and Regional Director of Clinical Services educated the Administrator and DON on BIMs assessment and scoring, staff to resident relations, police follow-up, and thorough investigations.
• The Administrator and DON educated the following staff members: Activities Director, Human Resources Director, Unit Manager, Wound Nurse, Maintenance Director, Social Services Director, Central Supply Clerk and Housekeeping Supervisor on BIMs assessment and scoring, staff to resident relations, police follow-up, and thorough investigations.
• The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to review the incident, the investigation, and the facility abuse policy not outlining physical and emotional contact between staff and resident.
• The facility completed a Brief Interview for Mental Status (BIMs) Assessment on all residents.
• All care plans were reviewed regarding cognitive status after the BIMS assessments were updated.
• The facility wound nurse completed skin assessments on all residents who had a BIMS of 12 or below.
• The facility Social Services Designee, Activity Director and the clinical management staff completed resident abuse questionnaires for residents with a BIMs score of 13 or above.
• All staff were educated on BIMs assessment and scoring, staff to resident relations, police follow-up, and thorough investigations.
• The facility notified the police department regarding the abuse allegation, re-opening of the facility investigation for sexual abuse and provided the alleged perpetrator's information.
• The facility implemented a plan to complete head-to-toe assessments on five random residents who had a BIMs score of 12 or less to assess for signs and symptoms of abuse, five times a week for four weeks then five residents weekly for four weeks.
• The facility would interview five random residents five times for four weeks and then five random residents weekly for four weeks with abuse questionnaires for residents with a BIMs of 13 or higher.
• The facility would complete five random staff questionnaires on new abuse policy five times a week for four weeks and then five random staff weekly for four weeks.
• RDO #201 and the Regional Director of Clinical Services would audit facility SRIs for a thorough and proper investigation.
• RDO #201 and the Regional Director of Clinical Services would audit SRIs for police notification.
• All discrepancies would be submitted to the QAPI Committee and revised as needed for three months.

Penalty

Inspection fine: $191,779

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean, sanitary, and well-maintained environment, as evidenced by multiple observations of damaged and soiled areas throughout the building. Specific findings included a large, broken bubble of plaster/paint on a resident's ceiling, moderately soiled carpets, dried paint and stains on doors and floors, peeling and torn wallpaper, water stains, bulging and damaged baseboards, and holes in walls in several resident rooms. The elevator interiors were found to be scratched and dirty, with missing flooring and heavily soiled entryways. Hallways and walk-through areas near nurses' stations were observed to have heavy scuff marks, scratches, and dirt. These conditions were verified by both the Assistant Director of Nursing and the Administrator during facility tours and interviews. The deficiency affected eight identified residents but had the potential to impact all residents in the facility, which had a census of 64 at the time. The facility's policy required regular cleaning and prompt attention to visibly soiled or contaminated surfaces, but observations indicated that these standards were not met. The findings were confirmed through interviews with facility staff, including the Administrator and a CNA, who acknowledged the presence of the damage and lack of cleanliness in the affected areas.

Penalty

Inspection fine: $191,779

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with a history of congestive heart failure, ischemic cardiomyopathy, and other cardiac conditions attended a physician-ordered follow-up cardiology appointment after returning from a hospital stay for shortness of breath and CHF exacerbation. Although the LPN entered the order for the follow-up appointment into the medical record, there was no documentation that the appointment was scheduled or attended. Both the LPN and the DON were unable to verify whether the appointment was arranged or completed, indicating a lapse in following through with physician orders for post-hospitalization care. Additionally, the facility did not ensure that wound care treatment orders were written and included in the care plan for a resident with a traumatic brain injury and multiple fractures who was receiving wound care for an open area on the left shin. The wound care was being performed as recommended by a visiting wound care service, but there was no corresponding order in the medical record, nor was the treatment addressed in the resident's comprehensive care plan. The wound nurse confirmed that the order for wound care had not been entered into the system, despite performing the treatment as directed by the wound care service.

Penalty

Inspection fine: $191,779

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate follow-up regarding optometry services for a resident with multiple cardiac diagnoses, including CHF, ischemic cardiomyopathy, and a history of sudden cardiac arrest. The resident was provided glasses by the facility's contracted optometry service, but later reported, through family, an inability to see out of the glasses. The Social Services Director (SSD) added the resident to the list for the next optometry visit but did not follow up to confirm if the resident was seen or if the issue was resolved. There was no documentation in the resident's medical record regarding vision or optometry services, and the SSD had not received any visit reports from the contracted optometry service since starting at the facility. These actions and omissions resulted in a lack of documented follow-up and unresolved vision concerns for the resident.

Penalty

Inspection fine: $191,779

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a certified nursing assistant (CNA) failed to follow infection control guidelines during incontinence care for a resident with multiple medical conditions, including left side hemiplegia, cognitive communication deficit, atrial fibrillation, and hypertension. The resident was dependent on staff for all activities of daily living and required enhanced barrier precautions due to a gastrostomy tube. Physician orders and the resident's care plan specified that staff were to use personal protective equipment (PPE), including gloves and a gown, during personal care. However, during an observed episode of incontinence care, the CNA donned gloves but did not wear a gown as required. During the care, the CNA removed soiled linens and a brief contaminated with fecal matter and placed them on the floor next to the resident's bed. After cleansing the resident's perineal area, the CNA, still wearing the same soiled gloves, touched clean linens and various surfaces in the room, including the over bed table and bed controls, without removing the gloves or performing hand hygiene. The CNA confirmed awareness of the enhanced barrier precautions but acknowledged not following them, including failing to don a gown and not performing hand hygiene before handling clean items. Facility policies required the use of both gown and gloves for high-contact care and specified hand hygiene after glove removal, but did not provide instructions for handling soiled linens and briefs after removal.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to provide basic life support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was found unresponsive on the toilet, despite the resident's advance directive indicating full code status. Certified Nursing Assistants (CNAs) discovered the resident in distress and alerted an LPN, who assessed the resident and found no pulse. Instead of initiating immediate CPR, the LPN sought guidance from another LPN on a different floor, who then contacted the Unit Manager at home for advice on locating the resident's advance directives. During this time, the LPN was unable to quickly access the resident's code status due to difficulties finding the medical chart and lack of immediate computer access. The delay in action resulted in no CPR being performed while staff attempted to confirm the resident's code status. EMS was contacted and arrived to find the resident deceased, with rigor mortis and other signs of irreversible death present. EMS staff indicated it was too late for resuscitation efforts. The resident was left slumped over on the toilet until EMS arrived, and staff did not attempt to move the resident or initiate life-saving measures as required by the facility's policy and the resident's documented wishes. The resident involved had a history of cognitive, social, and emotional deficits following cerebrovascular disease, mild vascular dementia, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, polyosteoarthritis, and a previous myocardial infarction. The resident's physician orders and care plan clearly indicated a full code status, meaning all life-saving measures were to be used in a medical emergency. Despite this, the staff's failure to promptly initiate CPR and their inability to access the resident's advance directives in a timely manner directly contributed to the deficiency.

Removal Plan

• The Director of Nursing (DON) provided education on Advance Directives, location of advanced directives, change of condition, and immediate response of CPR to all staff.
• Training was verified by review of sign in sheets.
• The DON and Administrator interviewed and/or collected statements from all staff working at the time of the incident involving Resident #61.
• A whole house audit of all residents was completed by the Regional Director of Clinical Services (RDCS) verifying code status, care plans and signed Do Not Resuscitate (DNR) forms.
• The Human Resource Director reviewed all nursing staff files to verify cardiopulmonary resuscitation (CPR) certifications were valid.
• The RDCS verified all laptops on the units were accounted for and available for nursing access.
• The DON audited crash carts to ensure all equipment was in place.
• An ADHOC Quality Assurance and Performance Improvement (QAPI) meeting was completed to discuss Advance Directives for all residents and develop education pertaining to Advance Directives, location of advanced directives, change in condition, and immediate response of CPR.
• A second ADHOC QAPI meeting was held to discuss code status levels, staff response expectations, and implementation/adjustment of the corrective action plan.
• Staff received education on advanced directives, location of the advanced directives, immediate response of CPR and change in condition by the RDCS and DON, with completion verified via sign-in sheets and random staff interviews.
• The facility implemented a plan for the DON/Designee to conduct Code Blue drills and location of advance directives on alternating shifts.
• The facility implemented a plan for the Administrator/Designee to audit all deaths to ensure resident's advanced directives were honored per preference.
• The facility implemented a plan for the DON/Designee to conduct audits to ensure that residents' change in conditions were addressed.
• The facility implemented a plan for the DON/Designee to conduct audits to ensure each unit had a laptop for nursing access.

Penalty

Inspection fine: $16,396

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to remain awake and alert while on duty, resulting in the potential for resident neglect on the second and third floors, affecting all 39 residents residing on those units. A resident with intact cognition reported that staff on the midnight shift were sleeping while call lights were going off, and provided videos and photos as evidence. The resident had reported this concern to the Administrator, who refused to review the videos, and the concern was marked as resolved without evidence of an investigation into the specific staff involved. Review of staffing schedules confirmed that on the nights in question, only one CNA was assigned to each floor, with LPNs splitting coverage. Video and photographic evidence showed CNAs sleeping at the nurse's station and in resident care areas while call lights remained activated and unanswered. Interviews with LPNs assigned to those shifts revealed they were unaware of staff sleeping and had not been asked to cover for CNAs during those times. Facility policy prohibits staff from sleeping while on duty, except during designated breaks in specific areas. The facility's abuse and neglect policy defines neglect as the failure to provide necessary goods and services to avoid harm or distress. The evidence provided by the resident, corroborated by the Regional Director of Operations, confirmed that staff were sleeping in resident care areas during their shifts, in violation of facility policy and resulting in a failure to protect residents from potential neglect.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper food handling and hygiene practices, as observed during a meal service. A staff member, identified as [NAME] #462, did not wear a beard net correctly, allowing his beard to be exposed during meal preparation and service. This was confirmed during an observation with the Regional Dietary Manager. Additionally, the same staff member used his hands to remove hamburger and hotdog buns from their bags instead of using appropriate utensils like tongs, as required by the facility's sanitation and infection control policy. The deficiency had the potential to affect 56 of the 59 residents, as three residents were noted to be NPO (nothing by mouth) and thus not directly impacted by the food handling practices. The facility's policies on hair covering and sanitation/infection control were reviewed and indicated that all exposed body hair should be effectively restrained and that appropriate utensils should be used for serving food.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received appropriate treatment and comprehensive care regarding the use of leg braces. The resident, who has diagnoses including schizoaffective disorder, borderline personality disorder, and polyosteoarthritis, was admitted with mild cognitive impairment and required extensive assistance for all activities of daily living. Despite the resident's desire to wear leg braces, there was no care plan or physician's order for the braces, and the facility staff were unaware of the need for them. The resident had refused therapy treatments on several occasions, and there was no documentation regarding the leg braces in the therapy notes. Interviews with facility staff revealed a lack of communication and documentation regarding the leg braces. The LPN was unaware of the braces, and the Infection Preventionist confirmed there was no order or care plan for them. The Occupational Therapist reported that the braces were delivered without notice, and the resident could not tolerate them, with no documentation of physician notification. The facility's policies on assistive devices and comprehensive care plans were not followed, leading to the deficiency in care for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #5 received his medication as ordered by the physician, which affected one resident out of three reviewed for medication administration. Resident #5, who had diagnoses including diabetes, pain in the leg, psychoactive substance abuse, asthma, and muscle weakness, was admitted to the facility and had intact cognition. On 07/22/24, the physician ordered pantoprazole 40 mg once daily for epigastric pain, but the order was not entered until 08/08/24, and the resident received his first dose on that date. The delay in medication administration was confirmed by interviews with the Regional Director of Clinical Services and the resident's family member, who reported that the medication was not administered for about two weeks after it was brought to the facility. Additionally, on 09/14/24, Resident #5 complained of nausea and vomiting, and the physician was notified, resulting in new orders for laboratory tests and Zofran 4 mg every six hours as needed. However, the September 2024 physician's order and Medication Administration Record revealed that Zofran was neither ordered nor administered. The Director of Nursing confirmed that no order for Zofran was written on 09/14/24, and the issue was acknowledged by the Ombudsman Supervisor, who noted that the resident and his mother had reached out to the Ombudsman due to the delay in receiving the medication. The facility's policy titled 'Administering Medications' dated 12/12 stated that medication should be administered in a safe and timely manner as prescribed. However, the facility did not adhere to this policy, as evidenced by the delay in administering pantoprazole and the lack of an order for Zofran. The Regional Director of Clinical Services confirmed that the facility was aware of the resident's physician appointments but did not follow up with the physician's office for new orders, contributing to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide therapy services to a resident after he won an appeal for additional therapy days. The resident, who had diagnoses including diabetes, leg pain, psychoactive substance abuse, asthma, and muscle weakness, was initially admitted with orders for physical and occupational therapy four times a week for four weeks. Despite being approved for additional therapy from August 6 to August 10, the resident did not receive these services. The therapy department did not resume therapy, citing that the resident did not need more therapy as he was independently walking with a walker. Interviews with facility staff revealed a lack of communication and documentation regarding the continuation of therapy services after the appeal was won. The Director of Therapy acknowledged that typically, therapy would continue for the certification period after a successful appeal, but this did not occur for the resident. The Regional Director of Operations confirmed there was no documentation indicating that the additional therapy days were solely for discharge planning, and the resident did not receive the approved therapy during this period. This deficiency was investigated under Complaint Number OH00157525.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the kitchen in a clean and sanitary manner, affecting 57 of 57 residents who received meals from the kitchen. During a kitchen tour, several unsanitary conditions were observed, including gnats flying around, a trash can with red and brown substances splashed on it, and a three-tiered silver cart with mixers that had dried food debris. Additionally, a trash can in the middle of the kitchen was dirty and lacked a lid, the steam table was dirty with dried food, and the shelf underneath it was dusty and dirty with food debris. The plate warmer and several three-tiered carts were also dirty with food buildup, and there was dirt and food debris on the floor of the freezer. Dietary Manager #635 confirmed these concerns during an interview, acknowledging that the steam table should be cleaned after every meal, trash cans should be cleaned and have lids, and freezers should be cleaned daily. The facility's policy, titled 'Cleaning and Sanitizing Dietary Areas and Equipment,' stated that all kitchen areas and equipment should be maintained in a sanitary manner and be free of food, grease, and other soil buildup. This deficiency was identified as an incidental finding during the investigation of a complaint.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its smoking policy, resulting in a failure to maintain a safe and clean environment. Observations were made of the resident smoking area and the side guest entrance, where numerous cigarette butts were found discarded in the mulch and on a window ledge. The administrator confirmed the presence of cigarette butts in these areas. The facility's smoking policy requires that cigarette butts and other smoking debris be discarded in designated receptacles and that staff keep the area free of debris at the end of each smoke break. This deficiency was identified during the investigation of a master complaint.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a palliative care consultation was arranged for a resident with chronic pain, identified as Resident #24. The resident was admitted with multiple diagnoses, including osteoarthritis, spinal stenosis, and chronic pain. On May 2, 2024, a nurse discussed pain management options with the resident, who expressed interest in palliative care. A request for a palliative care referral was sent to the nurse practitioner, and a physician's order for the referral was documented on May 4, 2024. However, there was no evidence that the resident had been seen for palliative care by the time of the survey. Interviews conducted during the survey revealed that the resident continued to experience pain related to spinal stenosis and had not received any follow-up regarding the palliative care consultation. The resident mentioned that the Director of Nursing had previously discussed the possibility of palliative care, but no further action had been taken. The facility administrator confirmed that no palliative care consultation had been completed for the resident as of the survey date. This deficiency was a repeat issue from a previous complaint survey conducted on June 27, 2024.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that pain medications were available and administered as ordered by the physician for a resident with chronic pain. The resident had a physician's order for Methadone HCl 80 mg to be taken twice daily for pain management. However, the Medication Administration Record (MAR) indicated that the resident did not receive the prescribed Methadone on several occasions in May and June 2024. Specifically, the medication was unavailable on multiple dates, and the nursing staff did not update the physician about the missed doses or the reduced dosage provided on one occasion. Interviews with the nursing staff and the resident confirmed the lapses in medication administration. The resident reported experiencing periods without her pain medication due to the nursing staff's failure to order the medications in a timely manner, although other as-needed pain medications were available. The facility's policy on administering medications, which requires medications to be administered according to the orders, was not followed. The nursing progress notes further documented the unavailability of Methadone and the lack of communication with the physician regarding these issues.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.