Date of Survey: 07/19/02
The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medical advisory committee and representatives of nursing and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each residents comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
All necessary precautions shall be taken to assure that the residents environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
The DON shall oversee the nursing services of the facility including planning an up-to-date resident care plan for each resident based on the residents individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician, shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
All mobile medication carts shall be under the visual control of the responsible nurse at all times when not stored safely and securely either in a locked room or otherwise made immobile.
These REQUIREMENTS are not met as evidenced by:
Based on interview and record review, the facility failed to provide supervision for two residents R 1 and
R 5: 1) to prevent a resident, R 5, from taking a controlled substance from the nurses' station without staff knowledge; 2) to prevent a resident, R 1, from taking a lethal dose of a Class II controlled substance from R 5 resulting in R 1 expiring of a drug overdose; 3) to immediately act on an incident of theft of a controlled substance by R 5 per facility policy; and 4) to monitor R 5 after behavioral changes, a suicidal ideation statement and following the theft of a medication by R 5.
1) Record review of the Resident Information Sheet, dated 5/4/02, revealed that R 5 was a 25 year old admitted to the facility on 2/25/02 with diagnoses including Bipolar Affective Disorder and Herpes Zoster. Resident Assessment dated 3/6/02, revealed that R 5 was assessed as having moderately impaired cognition with poor decisions, supervision required. R 5 is assessed as making negative statements, having persistent anger, self deprecation with socially inappropriate behaviors and verbally abusive. Review of R 5's Fall RAP (resident assessment protocol), dated 3/7/02, states that R 5 remains at risk for incidents related to a history of suicide attempt, substance abuse and aggressive behavior.
Record review of R 5's POS (physician order sheet), dated 5/1/02-5/31/02, revealed that R 5's medications ordered included MS Contin 100 mg three times daily (a Class II Controlled Substance).
Record review of R 5's "Initial Psychiatric Evaluation", at the hospital, dated 2/21/02, assessed R 5 as "labile, depressed and unpredictable and continued to be medication-seeking, demanding an increase in her opiate regimen." Review of R 5's "Psychiatric Examination", dated 2/25/02, revealed R 5 as assessed as having a "long-standing history of substance dependence, cocaine and opioids. The patient has had over 30 psychiatric hospitalizations over the years." On 5/7/02, per nurses' notes, R 5 was arrested for shoplifting. The nurses' notes, dated 5/8/02, state "according to DON (director of nursing) there are no restrictions for resident per DON." Review of the DON's progress note dated 5/8/02 revealed that R 5 returned from jail and stated to the DON "I just want to die." The DON does not address the suicidal ideations or shoplifting. Review of R 5's PRSC (psychiatric rehabilitative services counseling), dated 5/6/02, revealed that the counselors were aware of R 5's shoplifting incident and stated "discussed with resident the "rumors" of her shoplifting. Informed resident of inappropriateness and consequences caught of being arrested." Review of R 5's plan of care did not address R 5's shoplifting or the statement "I just want to die" nor did the plan of care evaluate R 5's medication seeking behaviors with specific interventions.
Review of R 5's "Psychosocial History", dated 3/4/02, revealed that R 5 was "in the process of rehabilitation from substance abuse (heroin and cocaine). Resident is a substance abuser, needs to be referred to (substance abuse) Center." Telephone interview with E 1, on 7/16/02 at 10:20 a.m., revealed that R 5 was referred to (substance abuse) Center but "one call was made but not documented." E 1 stated that there was no documentation regarding a
follow up to that phone call. Interview with E 2, on 7/12/02 at 3:05 p.m. in the 1st floor conference room, revealed that E 2 was not aware of such a referral.
Confidential telephone interview, on 7/16/02 at 9:20 a.m., revealed that R 5 was working as a housekeeper at the facility and observed R 5 clean the nurses' rotunda, empty garbage and pass evening snacks. Telephone interview with E 1, on 7/16/02 at 10:20 a.m., revealed that R 5 was in a paid work program as "an activity."
R 5 assisted staff and performed other functions.
2) Record review of the Resident Admission Sheet, dated 5/23/02, revealed R 1 was a 30 year old male admitted to the facility on 5/23/02 with diagnoses of Major Depression with Psychosis, Borderline Personality Disorder, Anxiety, Polysubstance Abuse, ETOH Abuse, Suicidal Ideation with Attempts and Klinefelters Syndrome. Record review of R 1's "Psychiatric Exam", dated 5/23/02, revealed that R 1 was "detoxed" at a hospital prior to R 1's admission to the facility with a "problem list" of poly substance abuse, depression and limited motivation. Record review of a hospital "neuropsychology Consultation Record", dated 5/13/02, revealed that on 5/8/02 R 1 was found unconscious from an overdose of heroin and had approximately 6 psychiatric hospitalizations since February 2002.
Record review of nurses' notes, dated 5/31/02, revealed that on 5/31/02 at 4:45 a.m., R 5 reported to E 4 that
R 1 was "not right and banging his head on dresser." E 4 documented R 1 "snoring loudly with brief periods of apnea. T.(temperature, unknown site) 97.4 P.(pulse) 117 and irregular. B/P. (blood pressure) 140/100. Unresponsive." E 5 documented R 1 turning gray and apnea periods prolonged to 2-3 minutes. At 5:05 a.m., R 1 was transported via ambulance to the hospital emergency room and admitted for a drug overdose.
Record review of R 1's "Notice of Determination Re: Pre-admission Screening, dated 5/22/02, revealed that "you are in need of more structure and supervision, admitted due to attempted O.D. (overdose) on Heroine, in need of Psychosoc. Rehab and medication monitoring." Review of the hospital physician note, dated 5/21/02, revealed that on 5/21/02, R 1 was "still quite anxious, the patient's drug seeking seems to be waning. He is still in need of tenure on this locked unit, given his near-death suicide attempt before admission, we need to move with caution around d/c (discharge)."
Record review of R 1's May 2002 MAR (medication administration record) revealed that R 1 was receiving Depakote 500 mg qam (every morning) and 1000 mg qhs (every evening). Review of the Mosby's Nursing Drug Reference 2002 revealed that Depakote and MS Contin interact causing increased CNS (central nervous system) depression. The side effects listed for MS Contin include bradycardia, shock and cardiac arrest. Review of R 1's MAR revealed that R 1 was also receiving Celexa 30 mg daily, Klonopin 20 mg twice daily, Haldol 2-4 mg every 2 hours as needed, Ativan 1-2 mg every 6 hours as needed, Cogentin 1 mg every 6 hours as needed, Desyrel 50 mg at bedtime and 400 mg of Testosterone monthly.
3) Review of R 6's Resident Assessment dated 5/27/02, revealed that R 6 was assessed as alert and oriented with cognitive independence. Interview with R 6, on 6/27/02 at 10:40 a.m. in R 6's room, revealed that R 6 witnessed R 5 take a narcotic medication card from Z 1's medication cart on 5/30/02 at 7:45 p.m. R 6 stated that R 5 was behind the nurses' station fixing
herself a cup of lemonade. R 6 stated that when Z 1 went to answer the phone, R 5 "took the card to her chest. She saw that I saw her take them. She went to her room." R 6 stated that she told Z 2 about her observation. At approximately 9:00 p.m., R 5 approached Z 1 demanding her MS Contin during the 9 p.m. medication pass. R 6 stated that when she and Z 2 came back from the store, at approximately 10:00 p.m., Z 1 told Z 2 that "pills were missing, MS Contin was taken." Z 1 revealed R 5's missing MS Contin during the 9:00 p.m. medication pass when R 5 requested her MS Contin. R 6 stated that at approximately 11:30 p.m., R 1 and R 5 were in the employee break room together. R 6 stated that R 1 "looked high then, slurring at the mouth." R 6 stated that the night nurse came into the employee break room and R 5 said something "smart" to her. R 6 stated that the night nurse did not pay attention to anyone, "just tells us what to do." R 6 stated that R 5 and R 1 went into R 5 's room and at 4:30 a.m., R 6 stated that R 1 was blue/gray and taken to the hospital. R 6 stated that the facility searched R 5 's room that morning and that R 5 signed herself out of the facility at approximately 10:30 a.m. (AMA) against medical advice.
Record review of Z 1's statement, dated May 30, 2002, revealed that R 6 witnessed R 5 "take a card of medication off this writers' nurse's cart." At 10:00 p.m., Z 1 was unable to locate the card of MS Contin. Z 1 stated that she confided in her "co- LPN (licensed practical nurse) that she was missing medication and called E 2. Z 1 stated that E 2 told her there was no incident or narcotic form to complete and stated "just write me a note, slip it under my office door, and I'll follow up on it in the morning. Right now I don't have enough people out there tonight to do a floor search." E 2 told Z 1 that she did not need to monitor R 5 for increased sedation because "you don't have to worry about her (R 5) overdosing, that should be your last concern, trust me, she will not overdose. I'll follow up on it in the morning, besides I know her hiding spots."
Record review of the facility's policy on "Accidents and Incidents-Investigating and Recording: revealed that "regardless of how minor an accident or incident may be, it must be reported to the department supervisor. The charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident."
Record review of a statement by E 1, dated 5/31/02, revealed that E 1 counseled E 2 "regarding the importance of timely implementation of the Accident/Incident Policy and promptness of implementation when informed of incidents." Record review of a "Memo" dated 7/4/02 revealed that Z 1 and Z 2 were suspended from further services at the facility.
Record review of a written statement by E 2, on 6/3/02, confirmed Z 1's statement on 5/30/02. Interview with E 2, on 6/27/02 at 11:10 a.m., revealed that E 2 received a telephone call from Z 1 at 10:30 p.m. at home. E 2 stated that Z 1 reported missing 14 tablets of morphine and that R 5 was witnessed taking the medication. E 2 stated that she told Z 1 to put a note on her door. E 2 stated that she told Z 1 that R 5 "will not overdose. I know (R 5) that well. I told (Z 1) that she did not have to monitor her." E 2 stated that she received another call in the morning stating that R 1 was found in R 5 's room unresponsive and told E 4 to tell the paramedics about the morphine incident. E 2 stated that she searched R 5 's room in the morning but did not find the medication card until a second search was done at 3:30 p.m. on 5/31/02 at which time the empty MS Contin card was found in R 5's room. E 2 stated that "if I get a call like that again, I would come right in and search the room."
Interview with E 7, on 6/27/02 at 12:20 p.m. in the 1st floor conference room, revealed that she interviewed
Z 1 and Z 2. E 7 stated that Z 2 did not tell Z 1 about R 6 's observation of R 5 taking the medication card because Z 2 thought R 6 "was a liar" and Z 2 did not believe her. E 7 stated that interviews with Z 1 and Z 2 revealed that they did not search R 5's room.
Telephone interview with E 4, on 7/10/02 at 3:35 p.m., revealed that E 4 was aware of the missing medication and the possibility that R 5 took the medication. E 4 stated that she was told by E 2 that she would "take care of it in the morning." E 4 stated that she did not search R 5's room and was told that R5 did not need to be monitored.
Record review of the "Police Department Synopsis Sheet", dated 6/28/02, revealed a statement by R 5 confessing that "she had stolen the morphine from the nurses station at the facility and had given it to (R 1) so he could get high." R 5 was charged by the County's State's Attorney for Drug Induced Homicide (Class X), Delivery of Controlled Substance and Possession of Controlled Substance. Review of the County Coroner Toxicology Report dated 6/14/02 revealed that R 1's Morphine Concentration Level was 285 ng/ml (nanograms per milliliter) with the lethal range being 200-2,300 ng/ml.