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The information reviewed during the unannounced special monitoring survey on November 16, 2023, provided evidence the facility failed to substantially comply with this condition of participation by failing to provide a safe environment for a patient on a Detox Unit. Video surveillance clearly showed a staff member completing rounds inconsistent with established facility policies and procedures.
A discussion took place with the survey team and the facility's administrative staff (EMP7), (EMP9), and (EMP10) regarding the survey team's concerns related to Patient's Rights on November 16, 2023, at 5:29 PM.
Cross reference
§482.13 (c)(2) Patient Rights: Care in a Safe Setting

Based on review of facility security video, policy and procedures, facility documents, medical records (MR) and interviews with staff (EMP) it was determined the facility failed to maintain a safe setting for patients on a Detox Unit.
Review on November 15, 2023, of security footage D'Arclay 2 East Hallway, revealed, on October 27, 2023, at 2:28 PM, PT1 is observed entering their room, and after this time (2:28 PM), PT1 is not observed out of their room. At 5:00 PM EMP8 is observed walking past the doorway of PT1's room to open the door of the unit for another staff member. At 5:01 PM, EMP8 is observed outside the doorway of PT1's room and does not enter the room. At 5:35 PM, EMP8 is observed walking into PT1's room. At 5:36 PM EMP8 is observed to leave the room to find another staff member and they both enter PT1's room.
Review on November 15, 2023, of facility policy, "Patient Safety Rounds-15 Minute, 30 Minute and Hourly" Revised July 2022, revised July 2022, revealed, "...PURPOSE: To establish levels of patient safety round and observation that provide each patient with optimal level of safety in the least restrictive manner, depending on their level of care and nursing unit ....30 Minute Rounding Responsibilities (Detox Units D'Arclay 2 east and D'Arclay 2 West Units ...During waking hours, observations should include "checking in" with the patient verbally to ensure their safety and well-being and identify any needs they may have or need for further assessment of intervention ...Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress ...Observations may not be completed standing in doorway or at a distance particularly for patient who are sleeping. It is expected that staff will enter the room, approach the patient and check their identity, respirations and ensure they are not in any distress ...If a patient is asleep, face and chest movement must be visualized.
Review of facility document, "Resident Rights and Responsibilities" revised July 2021, revealed, "...As our Resident, you have the right to safe, respectful, and dignified care at all times..."

Review on November 15, 2023, of MR1's Nurse Progress Note revealed on October 27, 2023, at 6:00 PM, Patient found in bed unresponsive to verbal and touch stimuli. Nurse was unable to find patient's pulse. CPR was initiated and Narcan was administered twice with no effect.
Review on November 15, 2023, of MR1's Nurse Progress Note revealed on October 27, 2023, at 9:44 PM revealed, at 5:50 PM police and paramedics arrived on-site to continue life saving measures. At 6:03 PM Paramedics discontinued life saving measures.
Interview with EMP7 on November 15, 2023, at 2:07 PM confirmed on October 27, 2023, at 5:01 PM, EMP8 did not enter PT1's room and EMP8 completed rounding from the doorway. Further interview with EMP7 confirmed the rounds completed for PT1 on October 27, 2023, at 5:01 PM did not follow established facility policy and procedures.