**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when the resident experienced a change in condition for 1 of 8 residents (Resident #55) reviewed for a change in condition. The facility failed to notify the physician when Resident #55 was pocketing Oxycodone pills on [DATE]. Resident #55 was found unresponsive and was sent to the local hospital on [DATE] for respiratory distress. The local hospital sent her to an inpatient behavioral hospital where she was admitted due to worsening of mood and suicidal attempt by drug overdose. An immediate jeopardy (IJ) was identified on [DATE] at 5:21 p.m. While the IJ was lowered on [DATE] at 2:33 p.m., the facility remained out of compliance at a severity level of more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for hospitalization and death. Findings include: Record review of Resident #55's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included quadriplegia C1-C4 incomplete (a spinal cord injury that blocks some, but not all, signals from getting through), major depressive disorder, scoliosis (sideways curvature of the spine or back bone), hypotension (low blood pressure), pain, and polyneuropathy (damage to multiple peripheral nerves). Record review of Resident #55's Hospital Paperwork dated [DATE] revealed she had a past medical history of IV heroin abuse. Record review of Resident #55's Psychiatric Subsequent assessment dated [DATE] read in part, .Review of History: Social Hx: drug use: per chart IV drug abuse Heroin. Pt denied . Record review of Resident #55's annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. She had symptoms of little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, feeling tired or having little energy, poor appetite, or overeating, feeling bad about yourself, and trouble concentrating on things. The total severity score was 21 out of 27 which indicated severe depression. She was dependent on staff for ADLs except for eating and oral hygiene. Record review of Resident #55's Physician Orders for [DATE] included: -Oxycodone 10 mg 1 tablet by mouth every 4 hours as needed for pain, order date [DATE]. Discontinued [DATE] transferred to hospital. Record review of Resident #55's nursing note dated [DATE] at 8:13 a.m. written by LVN P read in part, .Resident is pocketing pills in the mouth and take Oxycodone out per assigned CAN (sic) . Record review of Resident #55's nursing notes from [DATE] - [DATE] revealed there was no further documentation on Resident #55 pocketing pills or notification to the MD. Record review of Resident #55's Medication Administration Record from [DATE] - [DATE] revealed Oxycodone 10 mg give 1 tablet every 4 hours as needed for pain was documented as administered approximately 74 times to Resident #55 by various nurses. Record review of Resident #55's Controlled Drug Administration Record Tablet for Oxycodone 10 mg every four hours as needed for pain dated [DATE] revealed facility staff administered 60 tablets of Oxycodone to Resident #55 between [DATE] - [DATE]. Record review of Resident #55's Controlled Drug Administration Record Tablet for Oxycodone 10 mg every four hours as needed for pain dated [DATE] revealed facility staff administered 48 tablets of Oxycodone to Resident #55 between [DATE] - [DATE]. Record review of Resident #55's nursing note dated [DATE] at 6:07 a.m. written by LVN T revealed the resident was in respiratory distress. Placed O2 at 6L for comfort via NC. O2 saturations at 68%. Record review of Resident #55 's nursing note dated [DATE] at 8:40 a.m. written by RN E revealed CNA walked into the room and found patient unresponsive, was called at 6:40 a.m. to the room and found patient having agonal breaths (abnormal pattern of breathing characterized by labored, gasping breaths that occur because of insufficient oxygen), pupils reactive, and a thready pulse (a weak or absent pulse). The vital signs oxygen saturation at 68%, was not able to get a blood pressure and pulse reading, rapid response activated. At 6:50 a.m. the emergency response arrived; patient transferred to hospital. Record review of Resident #55's local hospital emergency department record dated [DATE] read in part, .stated complaint: suicide attempt; chief complaint: change mental/neuro status . pt found at (nursing facility) by staff as unresponsive with no pulse. Staff began CPR and realized pt had DNR. Staff got pulse back and per medic pt was agonal breathing and had bp of 74/39 and HR of 74 upon arrival .medication prior to arrival: Naloxone (used for the emergency treatment of known or suspected opioid overdose) Suicide assessment: wish to be dead or to not wake up in the past month: yes; . active suicidal ideation with plan and intent in the past month: yes; . attempted, plan to attempt, or prepared to end life in the past 3 months: yes; . calculated suicide risk level: high risk . emergency notes: This RN did suicide screening on pt. Pt states that she is not active suicidal and does not wish to be dead but wishes that the pain would go away. When asked by this RN if Pt took more Oxycodone than she was supposed to take, Pt said yes. Pt also stated that she never meant to harm herself that she just wanted the pain to go away and that was the reason why she took more Oxycodone than prescribed. Pt denies suicidal ideations at this time . Record review of Resident #55's local hospital record dated [DATE] read in part, .HPI: 46 y/o female with pmh of anxiety, PE, anemia and quadriplegic due to spinal infection with chronic pain admitted after she was found unresponsive at the NH. Per report, CPR initiated, was more awake upon EMS arrival. She was AAOx4 upon arrival to the ER. She reports had taken more pain medication to help control her pain. Denies suicidal ideations, she reports just wanted to end her pain . Diagnosis, Assessment and Plan: 1. Drug overdose- ? suicidal attempt - sitter at bedside, psych consulted . Record review of Resident #55's hospital Psychiatric Evaluation Note dated [DATE] read in part, .Patient evaluated and events noted . one to one sitter at bedside. Patient is alert and oriented x 3, calm, cooperative and pleasant. She stated that the reason that she took too many pills was because she was in pain, she stated that it was not intentional. She denied SIHI (suicidal ideations homicidal ideations) and AVH (auditory verbal hallucinations), no paranoia or delusions elicited . as per the treatment team, patient pocketing her pain medications at the nursing home so she can overdose on medications. Record review of Resident #55's hospital Psychiatric Progress Note dated [DATE] read in part, .calm and polite, denies intent to harm self . Assessment: major depression severe without psychosis, rule out substance abuse . Plan . transfer to inpatient psychiatry once medically cleared, with sitter continue for now . states the overdose was not intentional and was not an attempt. When gently confronted further patient states she takes the medicine for pain. She does not like her nursing home and does not wish to return there. Patient states she only took 10 pills throughout the day . Record review of Resident #55's Application for Emergency Detention dated [DATE] revealed there was reason to believe and belief that Resident #55 evidenced a substantial risk of serious harm to herself because of: pt. overdosed on pills in attempt to commit suicide, pt is anxious and agitation, pt is depressed. The beliefs were based on: pt. insight and judgement limited/poor and pt is a harm to herself. Record review of Resident #55's local hospital record dated [DATE] read in part, Discharge to: psych, facility . discharge date : [DATE] discharge diagnosis: 1.drug overdose/suicidal attempt . Hospital course: .presented after she was found unresponsive after drug overdose as an attempt to suicide. Psych evaluated pt, recommended for inpatient psych transfer . remains stable, will transfer to (behavioral hospital) . Record review of Resident #55's Behavioral Hospital Record dated [DATE] read in part, .reason for admission . include chief complaint in patient's own words: Patient admitted to inpatient behavioral facility from hospital due to worsening of mood and suicidal attempt by drug overdose. Patient had a long history of mental illness with history of depression and anxiety. As per records patient took 10 pills of oxycodone throughout the day. Patient was pocketing her pain medication at nursing home so that she could overdose on medication . The patient was assessed to be a danger to herself and required inpatient level of care for further evaluation and treatment in a controlled environment. Upon initial evaluation . patient endorsed having depressed mood and anxiety. Patient mentioned I don't want to go back to the same nursing home again which I was staying, I don't like the people there . Patient endorsed feelings of helplessness or hopelessness. Patient reported being compliant with medications prior to arriving to the hospital . Patient is being monitored every 15 for suicidal precautions . Record review of Resident #55's MD progress note dated [DATE] read in part . resident was seen today after recent hospital admission for respiratory distress, and O2 sat of 68 possible due to overdose of pain meds, patient was stabilized, but required inpatient psych due to worsening mood and suspected drug overdose . Diagnosis, assessment and plan: chronic pain: given patient's possible overdose and pocketing of pain meds that sent her to the hospital, I will decrease her oxycodone from every 4 hour to every 6 hour and also continue methadone at her regular dose . She is not getting her vitals done, so I will cut back further on pain meds if I have to. I take this question of overdose very seriously. She is on baclofen (used to treat muscle spasms). I will not add back her tizanidine ( used to treat muscle spasms) at this time . Record review of Resident #55's care plan revisions after her hospital stay on [DATE] revealed Resident #55 had impaired cognitive function and impaired thought processes related to cognitive decline and depression. Increased risk for personality changes, poor judgment, delusions, agitation, withdrawing from social contact, dated [DATE]. Resident #55 had a mood problem related to factors such as loss of independence, short temper, history of behavioral issues, major life changes, depression, little interest/pleasure in doing things. Interventions were to administer medications as ordered, assist the resident to identify strengths, positive coping skills and reinforce these, and educate the resident regarding expectations of treatment, etc, monitor mood to determine if problems seem to be related to external causes; report to MD prn acute episode feelings or sadness; feelings of worthlessness or guilt; report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols, date initiated [DATE]. There was no documentation of Resident #55 pocketing pills, her opioid overdose, or suicidal attempt notated in her clinical record. In an observation and interview on [DATE] at 8:45 a.m. with Resident #55 in her room, she was lying in bed awake. She said she had one previous hospitalization. When asked why she was hospitalized , Resident #55 said what? My overdose? If you are curious about my overdose you can leave. Interview ended. Interview on [DATE] at 9:44 a.m. with LVN T, he said he did not see Resident #55 pocket medications but received a report that Resident #55's Oxycodone was found in a cup before she went to the hospital (on [DATE]). He said after the incident, he started to enforce that the resident swallowed her medication, but she would refuse to open her mouth. He said he ensured she did not pocket the medication, but the resident would get upset because she felt they treated her like a child. He said he could not look in her mouth and would ask if she swallowed the medication. Interview on [DATE] at 10:37 a.m. the NP said a Nurse informed him that Resident #55 overdosed after she went to the hospital. He said he and the MD were trying to wean her down as much as possible. He said after she returned from the hospital, he informed the nurses to watch the resident take her pills and have her open her mouth to show that she swallowed the medication. Interview on [DATE] at 11:04 a.m. with the MD, he said he was not aware that Resident #55 was pocketing pills prior to her incident in November. He said if he was notified, he would have stopped the medication and had a conversation and plan to prevent it. He said when Resident #55 returned from hospital she told him what she did was intentional, she did not want to be here, she wanted to kill herself, and she was angry that she was not successful. He said staff should watch her take her pills and monitor for signs and symptoms. He said signs of oxycodone overdose were lethargy (a feeling of fatigue, tiredness and exhaustion both physically and mentally), hypoxia (below-normal level of oxygen in your blood), and low blood pressure. Interview on [DATE] at 11:55 a.m. with the Unit Manager, she said she was not aware Resident #55 was pocketing pills. She said Resident #55 went into distress and was sent out 911. She said after the resident returned from the hospital the resident told her: I tried to, that was on purpose . I know I messed up and I know why the MD changed the medication to every 6 hours. Interview on [DATE] at 12:33 p.m. with the ADON she said she was not aware Resident #55 was pocketing pills prior to the incident in November. She said they would have notified the doctor and intervened if they knew. She said on the day of the incident, nurses and CNAs called her and said the resident was lethargic and unresponsive and they called 911 immediately. She said the hospital called and were concerned about her mental health. The hospital was not releasing the resident back to the facility and she needed to go to inpatient therapy. The ADON said when the resident returned to the facility the resident said to her you will pay for it, I should have died. She said the resident informed her that she was taking too much and was holding them in, because she wanted to die. She said the resident told her that but then reverted and changed the story to get her way. She said prior to the incident the resident would request that staff leave her pain medication in the room, but the ADON informed staff that could not be done, and staff had to stay in the room to ensure it was swallowed. She said the resident would say she was not a child and would curse and yell at the staff. She said signs of an opioid overdose would include low blood pressure and not arousable. Interview on [DATE] at 1:04 p.m. with the DON, he said he was not aware of Resident #55 pocketing medications. He said he was aware she went to the hospital because she was not responding and was sent to the behavioral hospital. He said he reviewed her clinicals from the behavioral hospital but did not observe any outliers. He said he was not aware of her overdosing or having suicidal thoughts. Interview on [DATE] at 1:49 p.m. with the Administrator, he said he was not aware that Resident #55 was pocketing pills. He said he had no knowledge of a drug overdose or history of suicidal ideation. He said she was unresponsive and was sent to the hospital and then to the behavioral hospital for additional psych help. He said if he was notified of her pocketing pills, he would have notified the MD and investigated. This Surveyor showed the Administrator Resident #55's nursing note from [DATE] about pocketing pills. He said he had not seen the note and was not informed of the incident. Interview on [DATE] at 6:54 p.m. with LVN P, he said on [DATE] CNA V informed him that she saw Resident #55 take her medication (Oxycodone) out of her mouth. He said he did not tell the MD or NP but informed the nurse on the next shift and placed it on the 24-hour report. He said he informed the next shift to be careful when administering medication to Resident #55 and ensure she swallowed the medication with water. He said he went to Resident #55's room to look for the medication but did not see anything. He said Resident #55 denied it, was mad, cussed him out, and thought he was accusing her. He said he did not report it to the physician because he did not have information to give him since he did not see the medication in the room. He said multiple people knew she had medication in her room, but he was the only one to document because he thought it needed to be followed up on. An interview was attempted on [DATE] at 9:42 a.m. with CNA V but was unsuccessful. Record review of the facility's Acute Condition Changes - Clinical Protocol policy dated 3/2018 read in part, .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician 8. The nursing staff will contact the physician based on the urgency of the situation . On [DATE] at 5:21 p.m. the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template was left with the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on [DATE] at 7:30 a.m.: PLAN OF REMOVAL - F580 Immediate actions: o DON and/or designee will educate nurses on [DATE] & [DATE] on physician notification regarding changes in condition and behavior. o Nurses will demonstrate competency in this education by completing a post-education questionnaire. Any nurse who is not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o DON and/or designee will educate nurses on [DATE] & [DATE] to ensure medications are taken appropriately by all residents. o Nurses will demonstrate competency in this education by completing a post-education questionnaire. Any nurse who is not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o DON and/or designee will educate nurses on [DATE] & [DATE] to ensure nurses are able to identify a behavioral or mental health change of condition that would require physician consultation. o Nurses will demonstrate competency in this education by completing a post-education questionnaire. Any nurse who is not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o The Interdisciplinary Team will update resident #55 care plan to include the following interventions: o Ensure resident swallows the medication. o Psych will continue to follow resident. o Notify physician of any change of condition related to suicidal behavior/self-harm. Compliance Date: [DATE] o The Interdisciplinary Team will audit residents' charts and interview alert and oriented residents to ensure that any resident who does display signs and symptoms of suicidal ideation/self-harm have appropriate interventions in place and physicians are notified. Compliance Date: [DATE] o The Interdisciplinary Team will review the 72-hour report to ensure that physicians have been notified of all changes of condition identified in this report. Compliance Date: [DATE] o Unit manager communicated with resident #55 physician regarding behavior, medications, and care plan. Compliance Date: [DATE] MONITORING: Record review of the Competency Assessment for Nurses and Med Aides revealed True/False questions for Notifying Physicians regarding change of condition and suicidal ideation/self-harm, and Ensuring medications are taken appropriately. There was also a Signs and Symptoms MD Notification Guide given to them regarding when to notify the physician. Record review of POR revealed Nurses and Med Aides were educated on Med Administration which discussed: prescription and dosage, route of administration, pocketing medication, patient education, timing, record keeping, monitoring, and storage. Record review of POR revealed Nurses were educated on Managing Suicide and Suicidal Ideation, including signs and symptoms and risk factors. Record review of resident # 55's care plan revealed an updated focus on a Risk for injury to self r/t suicidal ideations initiated [DATE]. Interventions included: Administer medications as ordered, monitor while swallowing medication to ensure she is not pocketing/cheeking medication, Notify physician of any change of condition related to suicidal behavior/self-harm, Nurses and Med Aides will ensure resident swallows the medication and doesn't pocket medications, Pscyh services to continue to follow resident, Refer resident to (name) Psych, and Review prescribed medication side effects. Record review of POR binder revealed a list of 92 residents that the Psychologist assessed on [DATE] and charts reviewed, and none of them had any suicidal ideations/self-harm issues. Social Services Director interviewed every resident able from [DATE] to [DATE] and none showed any signs of suicidal ideation or self-harm. Record review of the change in condition log revealed the IDT reviewed the 72hr report for all residents and found 13 changes in conditions. The MD had been notified with all of the residents. Record review of Resident #55's medical record revealed a progress note from LVN E on [DATE] at 10:54 pm that said she spoke with the MD regarding the resident's medications, behaviors, and plan of care. Parameters were received to hold/not administer Oxycodone if SBP less than 100 or HR less than 55. If resident refused to have BP/HR checked medication would not be administered for resident's safety. MD notified of alleged suicidal ideation attempt and stated he didn't feel it was a threat at this time. Staff would continue to monitor resident for s/s and would notify MD of any issues. Record review of In-services/training revealed Nursing Staff were trained on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. In-services given by the ADON with 17 nurse signatures. Med Aides were in-serviced on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. Training performed by the ADON with 3 med aide signatures. Nurse Aides were in-serviced on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. The ADON performed the in-service with 12 Nurse Aide signatures. There are 15 staff members left to perform in-services with the first shift being the night shift on [DATE]. Interview on [DATE] at 1:25 p.m. LVN O said she had in-services on suicidal ideation: what to look for, what to do, who to report it to, change in condition, and to watch them take the medications. Interview on [DATE] at 1:30 p.m. CNA A said she received in-services on suicidal ideation: to report it to the nurse asap, and to follow up, stay with the resident and not leave them alone, report a change in condition, and to check their mouth. Interview on [DATE] at 1:32 p.m. LVN N said she received in-services on suicidal ideations: to report it asap, don't leave them alone, notify the DON/MD/Admin/RP, and report a change in condition. Interview on [DATE] at 1:36 p.m. RN C said she received in-services on suicidal ideation: monitor the s/s, the med administration for suicidal residents, and change in condition. She also said she received in-services on abuse and the abuse coordinator. Interview on [DATE] at 2:15 p.m. the ADON said there were 15 staff members that still needed to be in-serviced. All have been contacted and know they cannot step foot on the floor until they complete the in-service. The first employee who has not been in-serviced is on the PM shift of [DATE]. He will be in-serviced as soon as he gets to the facility. The facility was notified the IJ was lowered on [DATE] at 2:33 p.m. however, the facility remained out of compliance, at a scope of pattern and a severity level of more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and failed to describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 8 residents (Resident #55) reviewed for care plans. The facility failed to put behavioral interventions in place for Resident #55 when she returned from the behavioral hospital on [DATE] after being treated for drug overdose and suicidal idealation into the care plan. An immediate jeopardy (IJ) was identified on [DATE] at 9:45am. It ws determined that an IJ existed from [DATE] through [DATE]. While the IJ was lowered on [DATE] at 4:08pm, the facility remained out of compliance at a severity level of more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of attaining/maintaining their highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of Resident #55's face sheet dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included quadriplegia C1-C4 incomplete (a spinal cord injury that blocks some, but not all, signals from getting through), major depressive disorder, scoliosis (sideways curvature of the spine or back bone), hypotension (low blood pressure), pain, and polyneuropathy (damage to multiple peripheral nerves). Record review of Resident #55's Hospital Paperwork dated [DATE] revealed she had a past medical history of IV heroin abuse. Record review of Resident #55's Psychiatric Subsequent assessment dated [DATE] read in part, .Review of History: Social Hx: drug use: per chart IV drug abuse Heroin. Pt denied . Record review of Resident #55's annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. She had symptoms of little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, feeling tired or having little energy, poor appetite, or overeating, feeling bad about yourself, and trouble concentrating on things. The total severity score was 21 out of 27 which indicated severe depression. She was dependent on staff for ADLs except for eating and oral hygiene. Record review of Resident #55's local hospital emergency department record dated [DATE] read in part, .stated complaint: suicide attempt; chief complaint: change mental/neuro status (overall condition of nervous system function) . pt found at (nursing facility) by staff as unresponsive with no pulse. Staff began CPR and realized pt had DNR. Staff got pulse back and per medic pt was agonal breathing (abnormal pattern of breathing characterized by labored, gasping breaths that occur because of insufficient oxygen) and had bp of 74/39 and HR of 74 upon arrival .medication prior to arrival: Naloxone (used for the emergency treatment of known or suspected opioid overdose) Suicide assessment: wish to be dead or to not wake up in the past month: yes; . active suicidal ideation with plan and intent in the past month: yes; . attempted, plan to attempt, or prepared to end life in the past 3 months: yes; . calculated suicide risk level: high risk . emergency notes: This RN did suicide screening on pt. Pt states that she is not active suicidal and does not wish to be dead but wishes that the pain would go away. When asked by this RN if Pt took more Oxycodone than she was supposed to take, Pt said yes. Pt also stated that she never meant to harm herself that she just wanted the pain to go away and that was the reason why she took more Oxycodone than prescribed. Pt denies suicidal ideations at this time . Record review of Resident #55's local hospital record dated [DATE] read in part, .HPI: 46 y/o female with pmh of anxiety, PE, anemia and quadriplegic due to spinal infection with chronic pain admitted after she was found unresponsive at the NH. Per report, CPR initiated, was more awake upon EMS arrival. She was AAOx4 [alert to person, place, time, and situation] upon arrival to the ER. She reports had taken more pain medication to help control her pain. Denies suicidal ideations, she reports just wanted to end her pain . Diagnosis, Assessment and Plan: 1. Drug overdose- ? suicidal attempt - sitter at bedside, psych consulted (mental health consultation) . Record review of Resident #55's hospital Psychiatric Evaluation Note dated [DATE] read in part, .Patient evaluated and events noted . one to one sitter at bedside. Patient is alert and oriented x 3, calm, cooperative and pleasant. She stated that the reason that she took too many pills was because she was in pain, she stated that it was not intentional. She denied SIHI (suicidal ideations homicidal ideations) and AVH (auditory verbal hallucinations), no paranoia or delusions elicited . as per the treatment team, patient pocketing her pain medications at the nursing home so she can overdose on medications. Record review of Resident #55's hospital Psychiatric Progress Note dated [DATE] read in part, .calm and polite, denies intent to harm self . Assessment: major depression severe without psychosis, rule out substance abuse . Plan . transfer to inpatient psychiatry once medically cleared, with sitter continue for now . states the overdose was not intentional and was not an attempt. When gently confronted further patient states she takes the medicine for pain. She does not like her nursing home and does not wish to return there. Patient states she only took 10 pills throughout the day . Record review of Resident #55's Application for Emergency Detention dated [DATE] revealed there was reason to believe and belief that Resident #55 evidenced a substantial risk of serious harm to herself because of: pt. overdosed on pills in attempt to commit suicide, pt is anxious and agitation, pt is depressed. The beliefs were based on: pt. insight and judgement limited/poor and pt is a harm to herself. Record review of Resident #55's local hospital record dated [DATE] read in part, Discharge to: psych, facility . discharge date : [DATE] discharge diagnosis: 1.drug overdose/suicidal attempt . Hospital course: .presented after she was found unresponsive after drug overdose as an attempt to suicide. Psych evaluated pt, recommended for inpatient psych transfer . remains stable, will transfer to (behavioral hospital) . Record review of Resident #55's Behavioral Hospital Record dated [DATE] read reason for admission: include chief complaint in patient's own words: Patient admitted to inpatient behavioral facility from hospital due to worsening of mood and suicidal attempt by drug overdose. Patient had a long history of mental illness with history of depression and anxiety. As per records patient took 10 pills of oxycodone throughout the day. Patient was pocketing her pain medication at nursing home so that she could overdose on medication . The patient was assessed to be a danger to herself and required inpatient level of care for further evaluation and treatment in a controlled environment. Upon initial evaluation . patient endorsed having depressed mood and anxiety. Patient mentioned I don't want to go back to the same nursing home again which I was staying, I don't like the people there . Patient endorsed feelings of helplessness or hopelessness. Patient reported being compliant with medications prior to arriving to the hospital . Patient is being monitored every 15 for suicidal precautions . Record review of Resident #55's care plan revisions after her hospital stay on [DATE] revealed Resident #55 had impaired cognitive function and impaired thought processes related to cognitive decline and depression. Increased risk for personality changes, poor judgment, delusions, agitation, withdrawing from social contact, dated [DATE]. Resident #55 had a mood problem related to factors such as loss of independence, short temper, history of behavioral issues, major life changes, depression, little interest/pleasure in doing things. Interventions were to administer medications as ordered, assist the resident to identify strengths, positive coping skills and reinforce these, and educate the resident regarding expectations of treatment, etc, monitor mood to determine if problems seem to be related to external causes; report to MD prn acute episode feelings or sadness; feelings of worthlessness or guilt; report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols, date initiated [DATE]. There was no documentation of Resident #55 pocketing pills, her opioid overdose, or suicidal attempt notated in her clinical record. Record review of Resident #55's MD progress note dated [DATE] read in part . resident was seen today after recent hospital admission for respiratory distress, and O2 sat of 68 possible due to overdose of pain meds, patient was stabilized, but required inpatient psych due to worsening mood and suspected drug overdose . Diagnosis, assessment and plan: chronic pain: given patient's possible overdose and pocketing of pain meds that sent her to the hospital, I will decrease her oxycodone from every 4 hour to every 6 hour and also continue methadone at her regular dose . Record review of Resident #55's Physician Orders for [DATE] included: -Oxycodone 10 mg give 1 tablet by mouth every 4 hours as needed for pain, order date [DATE]. Discontinued on [DATE] due to no vitals given so I need to decrease frequency to ensure safety. -Oxycodone 10 mg give 1 tablet by mouth every 6 hours as needed for pain, order date [DATE]. -Staff, if patient refuses vital checks, then hold pain meds for her safety. We need regular bp checks and oxygen checks per facility protocol and please put them in the computer, one time only for hypoxia (below-normal level of oxygen in your blood) for 5 days, order date [DATE], end date [DATE]. -Staff, please obtain hospital discharge summary from patient's admission to the hospital for hypoxia. (This is before she went to [behavioral hospital]) one time only for hypoxia for 5 days, order date [DATE], end date [DATE]. -Vital signs every shift, order date [DATE]. In an observation on [DATE] at 12:20 p.m. Resident #55 was lying in bed asleep with her breakfast tray at the bedside, uneaten. This Surveyor called residents name several times, but resident did not respond. Resident coughed and this Surveyor called her name again, but resident did not respond. In an observation on [DATE] at 1:11 p.m. Resident #55 was asleep in bed. Interview on [DATE] at 1:30 p.m. LVN D said Resident #55 slept on and off. He said she was currently on Oxycodone every 6 hours and asked for it every 6 hours. He said he had to ensure she swallowed the medication because she was not in the past. He said he monitored her respirations to ensure she was not sedated or overly medicated. He said she was getting her Oxycodone every 4 hours but now it was every 6 hours. He said she was hoarding her medications and not taking it and the MD changed it. Interview on [DATE] at 8:45 a.m. with Resident #55 in her room, she said she had one previous hospitalization. When asked why she was hospitalized , Resident #55 said what? My overdose? If you are curious about my overdose you can leave. Interview ended. Interview on [DATE] at 9:44 a.m. with LVN T, he said he had received a report that Resident #55 pocketed her Oxycodone and it was found in a cup before she went to the hospital (on [DATE]). He said after Resident #55 returned to the facility he started to enforce that she swallowed her medication, but she would refuse to open her mouth. He said he ensured she did not pocket the medication, but the resident would get upset because she felt they treated her like a child. He said he could not look in her mouth and would ask her if she swallowed the medication. He said Resident #55 requested her Oxycodone every 6 hours on the dot. He said he checked her respirations, temperature, and oxygen saturations once per shift and the medication aide checked her blood pressure and pulse. He said it was hard to do something different to prevent the incident from happening again because she was still on the same medication and refused for staff to look in her mouth. He said when she first returned from the hospital, she was not on the Oxycodone and her other medications were reduced. He said Resident #55 called the behavioral hospital to get her Oxycodone reinstated. He said he called Resident #55's NP and her MD restarted her Oxycodone but reduced it to every 6 hours instead of every 4 hours. Interview on [DATE] at 10:37 a.m. Resident #55's NP said a Nurse informed him that Resident #55 overdosed after she went to the hospital. He said he and the MD were trying to wean her down on her medication as much as possible. He said after she returned from the hospital, he informed the nurses to watch the resident take her pills and have her open her mouth to show that she swallowed the medication. Interview on [DATE] at 11:04 a.m. with the MD, he said he was not aware that Resident #55 was pocketing pills prior to her incident in November. He said if he was notified, he would have stopped the medication and had a conversation and plan to prevent it. He said he did not receive a discharge summary from the hospital and had to use clues from the discharge instructions on what happened. He said he requested that the facility please get the discharge summary (from the local hospital), but he never received it. He said when Resident #55 returned from the behavioral hospital the resident told him what she did was intentional, she did not want to be here, she wanted to kill herself, and she was angry that she was not successful. He said currently Resident #55 was pleasant and very manipulative and they worked to strike a balance. He said staff should watch her take her pills and monitor for signs and symptoms. He said signs of oxycodone overdose were lethargy, hypoxia, and low blood pressure. He said he made it clear to the facility that he wanted Resident #55 to see a pain medication physician and the facility was supposed to be finding someone. He said he was not worried about it happening again because he had faith in the staff and their eagerness to correct the situation. He said Resident #55 may want to do it again and could possibly get away with pocketing pills later down the road. Interview on [DATE] at 11:55 a.m. with the Unit Manager, she said after Resident #55 returned from the hospital the resident was upset that her pain medications and muscle relaxers were changed. She said the MD was worried about an overdose or the resident trying to kill herself but could not stop the medication because of withdrawals. She said the resident told her: I tried to, that was on purpose . I know I messed up and I know why the MD changed the medication to every 6 hours. Interview on [DATE] at 12:33 p.m. with the ADON she said she was not aware Resident #55 was pocketing pills prior to the incident in November. She said they would have notified the doctor and intervened if they knew. She said on the day of the incident ([DATE]), nurses and CNAs called her and said the resident was lethargic and unresponsive and they called 911 immediately. She said the hospital called and were concerned about her mental health. The hospital was not releasing the resident back to the facility and she needed to go to inpatient therapy. The ADON said when the resident returned to the facility the resident said to her you will pay for it, I should have died. She said the resident informed her that she was taking too much and was holding them in because she wanted to die. She said the resident told her that but then reverted and changed the story to get her way. She said the resident had not voiced suicidal ideations. She said things the facility was doing differently upon her return were as much as the resident permitted and in accordance with her resident rights. She said the facility encouraged her to get up, talked to her, and assessed her pain needs. She said nurses knew to stay in the room to ensure the medication was swallowed. Interview on [DATE] at 1:04 p.m. with the DON, he said he was not aware of Resident #55 pocketing medications. He said if he was aware he would have notified the MD and ensured the nurses made sure she took her pills. He said he was aware she went to the hospital because she was not responding and was sent to the behavioral hospital. He said he reviewed her clinicals from the behavioral hospital but did not observe any outliers. He said he was not aware of her overdosing or having suicidal thoughts. Interview on [DATE] at 1:49 p.m. with the Administrator, he said he was not aware that Resident #55 was pocketing pills. He said he had no knowledge of a drug overdose or history of suicidal ideation. He said she was unresponsive and was sent to the hospital and then to the behavioral hospital for additional psych help. This Surveyor showed the Administrator Resident #55's nursing note from [DATE] about pocketing pills. He said he had not seen the note and was not informed of the incident. He said the facility conducted a care plan meeting in her room the day before Resident #55 was found unresponsive in the facility. He said they gave her the facility's expectations (on call lights) and discussed frequent repositioning needs. He said he did not want her to feel like she was a burden and spoke with her about staff workload. He said Resident #55 was understanding, reasonable, and pleasant during the meeting. Interview on [DATE] at 6:54 p.m. with LVN P, he said on [DATE], CNA V informed him that she saw Resident #55 take her medication (Oxycodone) out of her mouth. He said he did not tell the MD or NP but informed the nurse on the next shift and placed it on the 24-hour report. He said he informed the next shift to be careful when administering medication to Resident #55 and ensure she swallowed the medication with water. He said he went to Resident #55's room to look for the medication but did not see anything. He said Resident #55 denied it, was mad, cussed him out, and thought he was accusing her. He said he did not report it to the physician because he did not have information to give him since he did not see the medication in the room. He said multiple people knew she had medication in her room, but he was the only one to document because he thought it needed to be followed up on. An interview was attempted on [DATE] at 9:42 a.m. with CNA V but was unsuccessful. Interview on [DATE] at 2:43 p.m. the Social Services Director said Resident #55 was on psych services every 14 days. She said she did not review hospital clinicals. She said the resident had no behaviors from her point of view and was not suicidal. She said that information would be in the care plan. Telephone interview on [DATE] at 4:31 p.m. with the MDS Nurse, he said Resident #55 had her annual MDS assessment after she returned from the psych hospital (on [DATE]) and her care plan was updated because the mood and behaviors triggered on the assessment. He said the resident was sent to the hospital and then to psych for behaviors. He said nothing was reported to him on suicidal ideations or overdose. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated 3/2022 read in part, .A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs . 8. The interdisciplinary team should review and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the resident has been readmitted to the facility from a hospital stay . Record review of the facility's Acute Condition Changes - Clinical Protocol policy dated 3/2018 read in part, .5. The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having additional complications . On [DATE] at 9:45am the Administrator was notified of the Immediate Jeopardy (IJ) due to the above failures. The IJ template was left with the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on [DATE] at 3:04pm.: PLAN OF REMOVAL - F656 Date of Compliance: [DATE] Facility Failure The facility failed to put interventions in place for Resident #55 when she returned from the behavioral hospital on [DATE] after being treated for suicidal ideations. Immediate Actions: o DON and/or designee will assess resident #55 for change in condition, medication overdose, or thoughts of suicidal ideation/self-harm. o Resident #55 was assessed [DATE] by the Assistant Director of Nursing and the Social Services Director. There were no indications of depression or suicidal ideations and the resident verbalized that they didn't have any thoughts, intent, method, and/or plan. o Care plan implemented to ensure: -resident swallows the medication, -psych will continue to follow resident, -updates to include status/condition of the resident. -and physicians will be notified of any change of condition related to suicidal behavior/self-harm. o DON and/or designee will educate staff to ensure all staff are knowledgeable about mental health/behavioral health needs as well as the reporting guidelines should they identify any concerns. o Staff will demonstrate competency in this education by completing a post-education questionnaire. Any staff not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o The Interdisciplinary Team will review progress notes during weekday clinical IDT meeting to identify any residents at risk of suicidal ideation/self-harm and update care plan as needed to meet resident's medical, nursing, mental, and psychosocial needs. o The Interdisciplinary Team will review care plans for new admission/readmissions to identify any residents at risk of suicidal ideation/self-harm and update care plan as needed to meet resident's medical, nursing, mental, and psychosocial needs. o DON and/or designee do random check during care plan meetings on resident's care plan to assure that it reflects current condition of resident upon admission, readmission, change in condition with appropriate goals and interventions to meet the resident's medical, nursing, mental and psychological needs. o DON and/or designee will educate staff to ensure all staff are knowledgeable about signs and symptoms of self-harm or suicidal ideation as well as the reporting guidelines should they identify any concerns. o The Interdisciplinary Team audited on [DATE] residents' charts and interview alert and oriented residents to ensure that any resident who does display signs and symptoms of suicidal ideation/self-harm have appropriate interventions in place and physicians are notified. No other residents affected. MONITORING: Record review revealed Resident #55 was assessed on [DATE] by the ADON and the Social Services Director, and there were no indications of depression or suicidal ideations. Record review also revealed the resident verbalized she did not have any thoughts, intent, method, and/or plan. Record review of the care plan revealed: Care plan implemented to ensure: - resident swallows the medication, - psychiatry will continue to follow resident, - updates to include status/condition of the resident. - and physicians will be notified of any change of condition related to suicidal behavior/self-harm. Record review of resident # 55's revised care plan revealed an updated focus on a Risk for injury to self r/t suicidal ideations initiated [DATE]. Interventions included: Administered medications as ordered, monitored while swallowing medication to ensure she was not pocketing/cheeking medication, notified physician of any change of condition related to suicidal behavior/self-harm, Nurses and Med Aides ensured resident swallowed the medication and did not pocket medications, Psychiatry services continued to follow resident, referred resident to (name) Psychiatry, and reviewed prescribed medication side effects. Record review confirmed ADON/Social Services Director assessed resident on [DATE] and there was no evidence of medication overdose, thoughts of suicide or self-harm. Record review confirmed Resident was educated to communicate any feelings of sadness/hopelessness along with positive coping mechanisms. Record review revealed staff were in-serviced on Managing Suicide and Suicidal Ideations and Signs and Symptoms MD Notification Guide. Record review of the facility's in-service meeting dated [DATE] revealed 5 staff were trained on care plans: all clinicals should be reviewed prior to and upon admission for new or readmitting residents. Information for clinicals should be added to care plans and communicated to direct care staff, where appropriate. All condition changes or behaviors should be added to care plans timely. The Inservice was conducted by the Administrator. The comments were that all care plan audits are to be completed by 11:59 p.m. on [DATE], per plan of removal for chart audits. Record review revealed IDT Meeting Sign-In sheets from [DATE]-[DATE]. There were also Change in Condition Monitoring sheets from [DATE]-[DATE] that detailed resident's conditions in the last 24hrs and if they needed to be sent to the hospital or had a change in condition. Record review revealed a list of admission Care Plan Audits that had been completed from [DATE]-[DATE]. Record review revealed the IDT audited and interviewed resident's on [DATE] to ensure no other residents had signs/symptoms of suicidal ideation/self-harm. According to record review, no other residents were identified. Interview with the Regional MDS Coordinator on [DATE] at 3:48pm, she confirmed they reviewed the baseline/comprehensive care plans as the residents came in and made sure a baseline care plan was in place within 48hrs, to ensure any behaviors were noted on there. She also said they reviewed all care plans every morning in their meeting to ensure they had everything that was needed on them, or they would update them at that time. Interview on [DATE] at 3:52pm with the Social Worker, she confirmed they (IDT) met daily to review admission/readmission notes and updated care plans. She said if the resident was a new admission, everything was triggered and put on a baseline care plan within 48hrs. If the resident was a re-admission, they looked through the hospital discharge notes and added anything new to the comprehensive care plan. She said they had the care plan meeting within 48hrs of the resident being admitted . Interview with the DON on [DATE] at 4:00pm, he revealed when they had new admissions, they ensured a baseline care plan was done within 24-48hrs after admission. He also said whenever a resident was sent to the hospital, he ensured the indication was added to the care plan. He said he also spot-checked care plans during the care plan meetings and as residents were discharged and admitted . In an observation on [DATE] at 4:05pm, the facility appeared to be clean with no concerns noted. There were no obvious signs of abuse/neglect noted to residents, and no foul odors noted. There was no yelling/moaning heard from residents and residents appeared to be cheerful and smiling. The facility was notified the IJ was lowered on [DATE] at 4:08pm however, the facility remained out of compliance, at a scope of pattern and a severity level of more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #55) reviewed for supervision. -The facility failed to put interventions in place to prevent overdose of medications when Resident #55 was first noticed by the staff on [DATE] pocketing medications including narcotics. Resident #55 was found unresponsive and was sent to the hospital on [DATE] for respiratory distress with a hospital discharge diagnosis of drug overdose/suicidal attempt. An immediate jeopardy (IJ) was identified on [DATE] at 5:21 p.m. While the IJ was lowered on [DATE] at 2:33 p.m., the facility remained out of compliance at a severity level of more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for hospitalization and death. Findings include: Record review of Resident #55's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included quadriplegia C1-C4 incomplete (a spinal cord injury that blocks some, but not all, signals from getting through), major depressive disorder, scoliosis (sideways curvature of the spine or back bone), hypotension (low blood pressure), pain, and polyneuropathy (damage to multiple peripheral nerves). Record review of Resident #55's Hospital Paperwork dated [DATE] revealed she had a past medical history of IV heroin abuse. Record review of Resident #55's Psychiatric Subsequent assessment dated [DATE] read in part, .Review of History: Social Hx: drug use: per chart IV drug abuse Heroin. Pt denied . Record review of Resident #55's Care Plan completed [DATE] revealed she was referred for psychiatry services related to depression . often angry with staff, accuse them of not doing their job, then refuse when they attempt to render care, revised on [DATE]. Interventions were to attend therapy. Resident #55 had a behavior problem related to giving statements about staff that could not be validated, revised on [DATE]. She received antidepressant medication related to depression and neuropathic pain, revised on [DATE]. Interventions included to monitor for target behaviors including self-isolation, refusal of care, poor appetite, insomnia. Report adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thought, withdrawal. There was no documentation on pocketing medications or history of drug use. Record review of Resident #55's annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. She had symptoms of little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, feeling tired or having little energy, poor appetite, or overeating, feeling bad about yourself, and trouble concentrating on things. The total severity score was 21 out of 27 which indicated severe depression. She was dependent on staff for ADLs except for eating and oral hygiene. Record review of Resident #55's Physician Orders for [DATE] included: -Oxycodone 10 mg 1 tablet by mouth every 4 hours as needed for pain, order date [DATE]. Discontinued [DATE] transferred to hospital. Record review of Resident #55's nursing note dated [DATE] at 8:13 a.m. written by LVN P read in part, .Resident is pocketing pills in the mouth and take Oxycodone out per assigned CAN (sic) . Record review of Resident #55's nursing notes from [DATE] - [DATE] revealed there was no further documentation on Resident #55 pocketing pills or notification to the MD. Record review of Resident #55's Medication Administration Record from [DATE] - [DATE] revealed Oxycodone 10 mg give 1 tablet every 4 hours as needed for pain was documented as administered approximately 74 times to Resident #55 by various nurses. Record review of Resident #55's Controlled Drug Administration Record Tablet for Oxycodone 10 mg every four hours as needed for pain dated [DATE] revealed facility staff administered 60 tablets of Oxycodone to Resident #55 between [DATE] - [DATE]. Record review of Resident #55's Controlled Drug Administration Record Tablet for Oxycodone 10 mg every four hours as needed for pain dated [DATE] revealed facility staff administered 48 tablets of Oxycodone to Resident #55 between [DATE] - [DATE]. Record review of Resident #55's nursing note dated [DATE] at 6:07 a.m. written by LVN T revealed the resident was in respiratory distress. Placed O2 at 6L for comfort via NC. O2 saturations at 68%. Record review of Resident #55 's nursing note dated [DATE] at 8:40 a.m. written by RN E revealed CNA walked into the room and found patient unresponsive, was called at 6:40 a.m. to the room and found patient having agonal breaths (abnormal pattern of breathing characterized by labored, gasping breaths that occur because of insufficient oxygen), pupils reactive, and a thready pulse (a weak or absent pulse). The vital signs oxygen saturation at 68%, was not able to get a blood pressure and pulse reading, rapid response activated. At 6:50 a.m. the emergency response arrived; patient transferred to hospital. Record review of Resident #55's local hospital emergency department record dated [DATE] read in part, .stated complaint: suicide attempt; chief complaint: change mental/neuro status . pt found at (nursing facility) by staff as unresponsive with no pulse. Staff began CPR and realized pt had DNR. Staff got pulse back and per medic pt was agonal breathing and had bp of 74/39 and HR of 74 upon arrival .medication prior to arrival: Naloxone (used for the emergency treatment of known or suspected opioid overdose) Suicide assessment: wish to be dead or to not wake up in the past month: yes; . active suicidal ideation with plan and intent in the past month: yes; . attempted, plan to attempt, or prepared to end life in the past 3 months: yes; . calculated suicide risk level: high risk . emergency notes: This RN did suicide screening on pt. Pt states that she is not active suicidal and does not wish to be dead but wishes that the pain would go away. When asked by this RN if Pt took more Oxycodone than she was supposed to take, Pt said yes. Pt also stated that she never meant to harm herself that she just wanted the pain to go away and that was the reason why she took more Oxycodone than prescribed. Pt denies suicidal ideations at this time . Record review of Resident #55's local hospital record dated [DATE] read in part, .HPI: 46 y/o female with pmh of anxiety, PE, anemia and quadriplegic due to spinal infection with chronic pain admitted after she was found unresponsive at the NH. Per report, CPR initiated, was more awake upon EMS arrival. She was AAOx4 upon arrival to the ER. She reports had taken more pain medication to help control her pain. Denies suicidal ideations, she reports just wanted to end her pain . Diagnosis, Assessment and Plan: 1. Drug overdose- ? suicidal attempt - sitter at bedside, psych consulted . Record review of Resident #55's hospital Psychiatric Evaluation Note dated [DATE] read in part, .Patient evaluated and events noted . one to one sitter at bedside. Patient is alert and oriented x 3, calm, cooperative and pleasant. She stated that the reason that she took too many pills was because she was in pain, she stated that it was not intentional. She denied SIHI (suicidal ideations homicidal ideations) and AVH (auditory verbal hallucinations), no paranoia or delusions elicited . as per the treatment team, patient pocketing her pain medications at the nursing home so she can overdose on medications. Record review of Resident #55's hospital Psychiatric Progress Note dated [DATE] read in part, .calm and polite, denies intent to harm self . Assessment: major depression severe without psychosis, rule out substance abuse . Plan . transfer to inpatient psychiatry once medically cleared, with sitter continue for now . states the overdose was not intentional and was not an attempt. When gently confronted further patient states she takes the medicine for pain. She does not like her nursing home and does not wish to return there. Patient states she only took 10 pills throughout the day . Record review of Resident #55's Application for Emergency Detention dated [DATE] revealed there was reason to believe and belief that Resident #55 evidenced a substantial risk of serious harm to herself because of: pt. overdosed on pills in attempt to commit suicide, pt is anxious and agitation, pt is depressed. The beliefs were based on: pt. insight and judgement limited/poor and pt is a harm to herself. Record review of Resident #55's local hospital record dated [DATE] read in part, Discharge to: psych, facility . discharge date : [DATE] discharge diagnosis: 1.drug overdose/suicidal attempt . Hospital course: .presented after she was found unresponsive after drug overdose as an attempt to suicide. Psych evaluated pt, recommended for inpatient psych transfer . remains stable, will transfer to (behavioral hospital) . Record review of Resident #55's Behavioral Hospital Record dated [DATE] read in part, .reason for admission . include chief complaint in patient's own words: Patient admitted to inpatient behavioral facility from hospital due to worsening of mood and suicidal attempt by drug overdose. Patient had a long history of mental illness with history of depression and anxiety. As per records patient took 10 pills of oxycodone throughout the day. Patient was pocketing her pain medication at nursing home so that she could overdose on medication . The patient was assessed to be a danger to herself and required inpatient level of care for further evaluation and treatment in a controlled environment. Upon initial evaluation . patient endorsed having depressed mood and anxiety. Patient mentioned I don't want to go back to the same nursing home again which I was staying, I don't like the people there . Patient endorsed feelings of helplessness or hopelessness. Patient reported being compliant with medications prior to arriving to the hospital . Patient is being monitored every 15 for suicidal precautions . Record review of Resident #55's care plan revisions after her hospital stay on [DATE] revealed Resident #55 had impaired cognitive function and impaired thought processes related to cognitive decline and depression. Increased risk for personality changes, poor judgment, delusions, agitation, withdrawing from social contact, dated [DATE]. Resident #55 had a mood problem related to factors such as loss of independence, short temper, history of behavioral issues, major life changes, depression, little interest/pleasure in doing things. Interventions were to administer medications as ordered, assist the resident to identify strengths, positive coping skills and reinforce these, and educate the resident regarding expectations of treatment, etc, monitor mood to determine if problems seem to be related to external causes; report to MD prn acute episode feelings or sadness; feelings of worthlessness or guilt; report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols, date initiated [DATE]. There was no documentation of Resident #55 pocketing pills, her opioid overdose, or suicidal attempt notated in her clinical record. Record review of Resident #55's MD progress note dated [DATE] read in part . resident was seen today after recent hospital admission for respiratory distress, and O2 sat of 68 possible due to overdose of pain meds, patient was stabilized, but required inpatient psych due to worsening mood and suspected drug overdose . Diagnosis, assessment and plan: chronic pain: given patient's possible overdose and pocketing of pain meds that sent her to the hospital, I will decrease her oxycodone from every 4 hour to every 6 hour and also continue methadone at her regular dose . She is not getting her vitals done, so I will cut back further on pain meds if I have to. I take this question of overdose very seriously. She is on baclofen. I will not add back her tizanidine at this time . Record review of Resident #55's Physician Orders for [DATE] included: -Oxycodone 10 mg give 1 tablet by mouth every 4 hours as needed for pain, order date [DATE]. Discontinued on [DATE] due to no vitals given so I need to decrease frequency to ensure safety. -Oxycodone 10 mg give 1 tablet by mouth every 6 hours as needed for pain, order date [DATE]. -Staff, if patient refuses vital checks, then hold pain meds for her safety. We need regular bp checks and oxygen checks per facility protocol and please put them in the computer, one time only for hypoxia for 5 days, order date [DATE], end date [DATE]. -Staff, please obtain hospital discharge summary from patient's admission to the hospital for hypoxia. (This is before she went to [behavioral hospital]) one time only for hypoxia for 5 days, order date [DATE], end date [DATE]. -Vital signs every shift, order date [DATE]. In an observation on [DATE] at 12:20 p.m. Resident #55 was lying in bed asleep with her breakfast tray at the bedside, uneaten. This Surveyor called residents name several times, but resident did not respond. Resident coughed and this Surveyor called her name again, but resident did not respond. In an observation on [DATE] at 1:11 p.m. Resident #55 was asleep in bed. Interview on [DATE] at 1:30 p.m. LVN D said Resident #55 slept on and off. He said she was currently on Oxycodone every 6 hours and asked for it every 6 hours. He said he had to ensure she swallowed the medication because she was not in the past. He said he monitored her respirations to ensure she was not sedated or overly medicated. He said she was getting her Oxycodone every 4 hours but now it was every 6 hours. He said she was hoarding her medications and not taking it and the MD changed it. Interview on [DATE] at 8:45 a.m. with Resident #55 in her room, she said she had one previous hospitalization. When asked why she was hospitalized , Resident #55 said what? My overdose? If you are curious about my overdose you can leave. Interview ended. Interview on [DATE] at 9:44 a.m. with LVN T, he said he did not see Resident #55 pocket medications but received a report that Resident #55's Oxycodone was found in a cup before she went to the hospital (on [DATE]). He said after the incident, he started to enforce that the resident swallowed her medication, but she would refuse to open her mouth. He said he ensured she did not pocket the medication, but the resident would get upset because she felt they treated her like a child. He said he could not look in her mouth and would ask if she swallowed the medication. Interview on [DATE] at 10:37 a.m. the NP said a Nurse informed him that Resident #55 overdosed after she went to the hospital. He said he and the MD were trying to wean her down as much as possible. He said after she returned from the hospital, he informed the nurses to watch the resident take her pills and have her open her mouth to show that she swallowed the medication. Interview on [DATE] at 11:04 a.m. with the MD, he said he was not aware that Resident #55 was pocketing pills prior to her incident in November. He said if he was notified, he would have stopped the medication and had a conversation and plan to prevent it. He said when Resident #55 returned from hospital she told him what she did was intentional, she did not want to be here, she wanted to kill herself, and she was angry that she was not successful. He said staff should watch her take her pills and monitor for signs and symptoms. He said signs of oxycodone overdose were lethargy (a feeling of fatigue, tiredness and exhaustion both physically and mentally), hypoxia (below-normal level of oxygen in your blood), and low blood pressure. Interview on [DATE] at 11:55 a.m. with the Unit Manager, she said she was not aware Resident #55 was pocketing pills. She said Resident #55 went into distress and was sent out 911. She said after the resident returned from the hospital the resident told her: I tried to, that was on purpose . I know I messed up and I know why the MD changed the medication to every 6 hours. Interview on [DATE] at 12:33 p.m. with the ADON she said she was not aware Resident #55 was pocketing pills prior to the incident in November. She said they would have notified the doctor and intervened if they knew. She said on the day of the incident, nurses and CNAs called her and said the resident was lethargic and unresponsive and they called 911 immediately. She said the hospital called and were concerned about her mental health. The hospital was not releasing the resident back to the facility and she needed to go to inpatient therapy. The ADON said when the resident returned to the facility the resident said to her you will pay for it, I should have died. She said the resident informed her that she was taking too much and was holding them in, because she wanted to die. She said the resident told her that but then reverted and changed the story to get her way. She said prior to the incident the resident would request that staff leave her pain medication in the room, but the ADON informed staff that could not be done, and staff had to stay in the room to ensure it was swallowed. She said the resident would say she was not a child and would curse and yell at the staff. She said signs of an opioid overdose would include low blood pressure and not arousable. Interview on [DATE] at 1:04 p.m. with the DON, he said he was not aware of Resident #55 pocketing medications. He said he was aware she went to the hospital because she was not responding and was sent to the behavioral hospital. He said he reviewed her clinicals from the behavioral hospital but did not observe any outliers. He said he was not aware of her overdosing or having suicidal thoughts. Interview on [DATE] at 1:49 p.m. with the Administrator, he said he was not aware that Resident #55 was pocketing pills. He said he had no knowledge of a drug overdose or history of suicidal ideation. He said she was unresponsive and was sent to the hospital and then to the behavioral hospital for additional psych help. He said if he was notified of her pocketing pills, he would have notified the MD and investigated. This Surveyor showed the Administrator Resident #55's nursing note from [DATE] about pocketing pills. He said he had not seen the note and was not informed of the incident. Interview on [DATE] at 6:54 p.m. with LVN P, he said on [DATE] CNA V informed him that she saw Resident #55 take her medication (Oxycodone) out of her mouth. He said he did not tell the MD or NP but informed the nurse on the next shift and placed it on the 24-hour report. He said he informed the next shift to be careful when administering medication to Resident #55 and ensure she swallowed the medication with water. He said he went to Resident #55's room to look for the medication but did not see anything. He said Resident #55 denied it, was mad, cussed him out, and thought he was accusing her. He said he did not report it to the physician because he did not have information to give him since he did not see the medication in the room. An interview was attempted on [DATE] at 9:42 a.m. with CNA V but was unsuccessful. Record review of the facility's Safety and Supervision of Residents policy dated 7/2017 read in part, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Facility Oriented Approach to Safety: .3. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause of the hazards and develop strategies to mitigate or remove the hazards to the extent possible . 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. 5. The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary . Individualized, Resident-Centered Approach to Safety . 2. The IDT shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff . c. providing training, d. ensuring that interventions are implemented; and e. documenting interventions. On [DATE] at 5:21 p.m. the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template was left with the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on [DATE] at 7:30 a.m.: PLAN OF REMOVAL - F689 Date of Compliance: [DATE] Immediate actions: o DON and/or designee will assess resident #55 for change in condition, medication overdose, or thoughts of suicidal ideation/self-harm. o Resident #55 was assessed by the Assistant Director of Nursing and the Social Services Director. There were no indications of depression or suicidal ideations and the resident verbalized that they didn't have any thoughts, intent, method, and/or plan. o DON and/or designee will continue to assess resident #55 for change in condition, medication overdose, or thoughts of suicidal ideation/self-harm 3x weekly for 4 weeks. o Care plan implemented to ensure resident swallows the medication, psych will continue to follow resident, and physicians will be notified of any change of condition related to suicidal behavior/self-harm. o Licensed Phycologist, , will assess resident #55 for suicidal ideation/self-harm on [DATE]. ? Per assessment by psychologist, resident #55 is doing well mentally and has no immediate concerns for her physical or mental wellbeing. She indicated that she loves speaking with her psychology team. Compliance Date: [DATE] o The Interdisciplinary Team will update resident #55 care plan to include the following interventions: o Ensure resident swallows the medication. o Psych will continue to follow resident. o Notify physician of any change of condition related to suicidal behavior/self-harm. Compliance Date: [DATE] o DON and/or designee will check resident #55 room for any pills or medications. Compliance Date: [DATE] o DON and/or designee will educate nurses and medication aides on to ensure medications are taken appropriately by all residents. o Nurses and medication aides will demonstrate competency in this education by completing a post-education questionnaire. Any nurse or medication aide who is not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o DON and/or designee will educate staff to ensure all staff are knowledgeable about mental health/behavioral health needs as well as the reporting guidelines should they identify any concerns. o Staff will demonstrate competency in this education by completing a post-education questionnaire. Any staff not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o DON and/or designee will educate staff to ensure all staff are knowledgeable about signs and symptoms of self-harm or suicidal ideation as well as the reporting guidelines should they identify any concerns. o Staff will demonstrate competency in this education by completing a post-education questionnaire. Any staff not in-serviced will be in-serviced and complete a post-education questionnaire before the start of their next shift. Compliance Date: [DATE] o The Interdisciplinary Team will audit residents' charts and interview alert and oriented residents to ensure that any resident who does display signs and symptoms of suicidal ideation/self-harm have appropriate interventions in place and physicians are notified. Compliance Date: [DATE] o DON and/or designee will conduct search of resident #55 and their belongings 3x/week for 4 weeks. Compliance Date: [DATE] o Unit manager communicated with resident #55 physician regarding behavior, medications, and care plan. Compliance Date: [DATE] o The Interdisciplinary Team will review progress notes during weekday clinical IDT meeting to identify any residents at risk of suicidal ideation/self-harm. Compliance Date: [DATE] o The Interdisciplinary Team has reviewed policies and procedures regarding self-harm and/or suicidal ideations along with the reporting guidelines once concerns are identified. o 'Depression - Clinical Protocol' o 'Acute Condition Changes - Clinical Protocol' Compliance Date: [DATE] MONITORING: Record review of Resident's progress notes revealed a note from [DATE] at 11:26pm stating Social Services Director and ADON assessed resident and there was no change in condition, no evidence of medication overdose and resident stated she had no current thoughts of suicide or self-harm. Progress note from [DATE] at 11:59 p.m. revealed ADON educated resident to communicate any feeling of sadness/hopelessness along with positive coping mechanisms. Resident was receptive and agreed and continued to deny and symptoms of suicidal ideations or sadness. DON and/or designee will continue to assess resident #55 for change in condition, medication overdose, or thoughts of suicidal ideation/self-harm 3x week for 4 weeks. Record review of audit sheet in POR binder. Licensed Psychologist assessed resident #55 on [DATE] and there were no psychological issues of concern. Record review of resident's care plan revealed an updated focus on a Risk for injury to self r/t suicidal ideations initiated [DATE]. Interventions included: Administer medications as ordered, Monitor while swallowing medication to ensure she is not pocketing/cheeking medication, Notify physician of any change of condition related to suicidal behavior/self-harm, Nurses and Med Aides will ensure resident swallows the medication and doesn't pocket medications, Pscyh services to continue to follow resident, Refer resident to (name) Psych, and Review prescribed medication side effects. Record review of Resident #55's medical record revealed a progress note from [DATE] at 11:26pm stating Social Services Director and ADON went into the resident's room to check for any pills or medications. They did not find any pills laying around on the bedside table, side tables, bed, or any other visible areas. Record review of the Competency Assessment for Nurses and Med Aides revealed True/False questions for Notifying Physicians regarding change of condition and suicidal ideation/self-harm, and Ensuring medications are taken appropriately. There was also a Medication Administration sheet given to them regarding prescription and dosage, route of administration, pocketing medication, patient education, timing, record keeping, monitoring, and storage. Record review of the education given regarding mental health/behavioral health needs included Signs/Symptoms of Suicide, Suicide Risk Factors, and Signs and Symptoms MD Notification Guide. Record review of In-services/training revealed Nursing Staff were trained on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. In-services given by the ADON with 17 nurse signatures. Med Aides were in-serviced on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. Training performed by the ADON with 3 med aide signatures. Nurse Aides were in-serviced on [DATE] regarding Physician Notification and Medication Management, Notifying Physicians Regarding Change of Condition and Suicidal Ideation/Self Harm, Ensuring Medications are Taken Appropriately by Resident, and Managing Suicide and Suicidal Ideations. The ADON performed the in-service with 12 Nurse Aide signatures. There are 15 staff members left to perform in-services with the first shift being the night shift on [DATE]. Record review of POR binder revealed a list of 92 residents that the Psychologist assessed on [DATE] and charts reviewed, and none of them had any suicidal ideations/self-harm issues. DON and/or designee will conduct search of Resident #55 and their belongings 3x week for 4 weeks. Record review of POR binder revealed Audit Sheet for resident. Record review of Resident #55's medical record revealed a progress note from LVN E on [DATE] at 10:54 p.m. that said she spoke with MD regarding the resident's medications, behaviors, and plan of care. Parameters were received to hold/not administer Oxycodone if SBP less than 100 or HR less than 55. If resident refused to have BP/HR checked medication would not be administered for resident's safety. MD notified of alleged suicidal ideation attempt and stated he didn't feel it was a threat at this time. Staff would continue to monitor resident for s/s and would notify MD of any issues. Record review of IDT meeting sign-in sheets revealed they had a meeting on [DATE] which included the Administrator, DON, ADON, Social Services Director, Staffing Coordinator, Medical Records, Activities, LVN E, Admissions, Director of Maintenance, and Director of Rehab. On [DATE] it was the same people, minus Social Services. On [DATE] it was the same people as [DATE]. On [DATE], the 24hr reports from [DATE] were reviewed for all residents. 3 residents were found to have issues. One c/o not feeling well and had n/v with BLE swelling. His K+ levels were elevated, so he was sent to the hospital. One complained of muscle spasms to L upper chest and had had this before. He requested a muscle relaxer. NP notified and EKG ordered. The last one had a seizure and dislodged PEG tube. All residents were assessed psychologically and had no concerns. Record review of facility's policy[TRUNCATED]