WHITE SETTLEMENT, TX - A nursing home staff member has been suspended following an investigation into allegations that they provided methadone to a resident who subsequently experienced respiratory distress and required emergency treatment with naloxone (Narcan).
Staff Member Allegedly Provided Unprescribed Methadone to Vulnerable Resident
The most serious violation at West Side Campus of Care involved a 64-year-old male resident with a history of substance abuse who was found unresponsive in his room on April 30, 2025. The resident had been experiencing respiratory distress and was transported to a local hospital, where medical tests revealed the presence of methadone in his system - a medication for which he had no prescription.
During the state investigation, the resident disclosed that he had received methadone from a staff member, stating "he became sick after taking Methadone that he received from a staff member" and that "he must have taken too much, and it caused him to pass out." The resident explained he was feeling sad about his mother's illness at another facility and "needed something to take his mind off it," but refused to identify which staff member provided the drug.
Hospital records documented that the resident arrived with severely compromised respiratory function, including an oxygen saturation of only 47% on room air and abnormal blood gas levels. Medical staff administered naloxone (Narcan), a medication specifically designed to reverse opioid overdoses, and the resident responded positively to the treatment.
The facility's response to this incident initially created additional compliance issues. While the Director of Nursing received the hospital records showing methadone in the resident's system on May 2nd, the facility did not report the suspected abuse to state agencies or law enforcement until May 6th - four days after learning of the positive drug test. Federal regulations require such reports within two hours of the suspicion or allegation.
Critical Oxygen Supply Failure During Medical Appointment
A separate immediate jeopardy situation occurred when a resident requiring continuous oxygen therapy ran out of oxygen during a medical appointment, resulting in emergency hospitalization. The 84-year-old female resident with chronic obstructive pulmonary disease (COPD) and emphysema was transported to an eye surgery consultation with what staff believed was a full portable oxygen tank.
During the appointment, which lasted longer than anticipated, the resident's oxygen supply became depleted. The surgical center gave the nursing facility 15 minutes to provide additional oxygen or they would call emergency services. "CNA D called and informed that Resident #2's oxygen was low, and the surgical center was giving the facility 15 minutes to bring more oxygen, or they were going to call 911," according to the Director of Nursing's statement.
The resident began experiencing chest pain and shortness of breath as her oxygen levels dropped. Emergency medical services transported her to the hospital, where she was diagnosed with pneumonia and required continued oxygen support. The resident described the frightening experience, noting that "her chest was hurting and she was short of breath so the 911 was called and after what seemed like an hour, she was transported to the hospital."
Investigation revealed that while the portable oxygen tank was checked before departure, the facility failed to account for the extended duration of the appointment and did not provide backup oxygen supplies. The tank, which should have lasted 3-4 hours at the prescribed flow rate, was insufficient for the actual appointment length.
Understanding the Medical Risks and Regulatory Violations
These violations represent serious breakdowns in fundamental care standards that placed residents in life-threatening situations. Methadone is a powerful synthetic opioid that can cause severe respiratory depression, particularly dangerous for elderly individuals with existing heart and lung conditions. When combined with other prescribed pain medications, as in this case, the risk of fatal overdose increases significantly.
The respiratory complications documented in the hospital - including dangerously low oxygen saturation and abnormal blood gases - indicate the resident experienced a potentially fatal medical emergency. Methadone's long half-life means its effects can persist for hours, making timely medical intervention crucial for survival.
Oxygen therapy failures present equally serious risks for residents with chronic respiratory conditions. COPD patients depend on continuous oxygen to maintain adequate blood oxygen levels and prevent organ damage. When oxygen supplies are interrupted, residents can quickly develop acute respiratory failure, heart complications, and other life-threatening conditions.
The facility's delayed reporting violated federal Elder Justice Act requirements designed to ensure rapid investigation and protection of vulnerable residents. This four-day delay potentially allowed continued access to unauthorized substances while placing other residents at risk.
Standard Protocols and Safety Requirements
Nursing facilities are required to maintain comprehensive drug and alcohol policies with zero tolerance for unauthorized substances. Staff must be trained to recognize signs of substance abuse and intoxication, with clear protocols for immediate reporting and intervention. Regular medication audits and secure storage systems are essential components of preventing drug diversion.
For oxygen-dependent residents, facilities must ensure adequate supplies for all activities, including medical appointments. This includes calculating oxygen duration based on flow rates, appointment length, and transportation time, with backup supplies provided for extended outings. Staff should verify tank levels immediately before departure and maintain emergency procedures for oxygen supply failures.
Federal regulations mandate immediate reporting of suspected abuse, neglect, or criminal activity to both law enforcement and state agencies. These requirements exist because delayed reporting can compromise investigations and allow continued harm to vulnerable residents.
Facility Response and Corrective Measures
Following the identification of these violations, West Side Campus of Care implemented extensive corrective measures. The facility suspended the staff member allegedly involved in providing methadone pending a full investigation and contacted law enforcement. All staff received mandatory retraining on drug and alcohol policies, abuse recognition and reporting, and naloxone administration procedures.
For oxygen therapy management, the facility developed new protocols requiring nurses to calculate appointment durations and provide backup oxygen tanks for any outing exceeding two hours. Staff were retrained on checking portable oxygen levels and received education on emergency procedures when oxygen supplies become inadequate.
The facility also established enhanced monitoring systems, including daily audits of residents with substance abuse histories and regular oxygen supply verifications. An ad hoc Quality Assurance meeting was conducted to review these failures and prevent recurrence.
Additional Issues Identified
During the investigation, inspectors noted other compliance concerns including inadequate investigation procedures when the facility first learned of the positive methadone test. The facility's initial response focused primarily on staff education rather than the comprehensive investigation and immediate reporting required by federal regulations.
The state survey revealed the facility lacked specific written policies for managing portable oxygen tanks during community outings, despite serving multiple residents requiring continuous oxygen therapy. This policy gap contributed to the inadequate preparation for the resident's medical appointment.
Both violations were classified as immediate jeopardy to resident health and safety, reflecting the serious nature of these care failures and their potential for causing significant harm or death to vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Side Campus of Care from 2025-05-08 including all violations, facility responses, and corrective action plans.
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