The upscale Sierra Tucson rehabilitation center has made several protocol changes following a state investigation into its treatment of a 20-year-old male patient who died of acute drug toxicity in April.

The man was at Sierra Tucson for drug rehabilitation. A state report into the death found problems with the facility’s pharmacy services, and found that staff members did not adequately check on the patient’s vital signs or follow the facility’s suicide assessment protocol.

The patient was found unresponsive at 8:45 a.m. on April 13. He died two days later.

Sierra Tucson, a for-profit facility north of Tucson, paid a $250 fine — an amount set by state statute — related to the way it followed its policies and procedures in its treatment of the patient who died. According to state officials, Sierra Tucson submitted a plan of correction and is now considered in compliance with Arizona licensing rules and regulations.

The state report does not describe precisely how the 5-foot, 8-inch, 162-pound patient acquired a toxic level of drugs in his system while in treatment, and an autopsy says the cause of death is undetermined.

Forensic pathologist Dr. Veena D. Singh wrote that it is unclear whether the lethal drug combination was intentional or accidental. Her report lists a combination of diazepam (Valium), nordiazepam (metabolized diazepam), chlordiazepoxide (Librium) and the muscle relaxant cyclobenzaprine (Flexeril) as the cause of death.

The patient’s family did not want to comment and asked the Star not to publish his name. Sierra Tucson Executive Director Philip Herschman did not return phone calls from the Star Thursday or Friday.

Before signing an enforcement agreement between Sierra Tucson and the state, documents show state officials discussed two concerns with Sierra Tucson officials — practices relating to the assessment of patients’ vital signs; and also concerns with documentation of suicide risk assessment and management.

Since the investigation, Sierra Tucson has begun a random patient-chart-monitoring program. Compliance with its suicide risk assessment and management policy will be monitored on a monthly basis by a random selection of at least 30 charts, according to the plan of correction. Staff training sessions on the facility’s suicide-prevention protocol also were conducted in May and June, Sierra Tucson officials said.

Also in the documents submitted to the state in October, Sierra Tucson says it has revised its major medication interaction protocol since the death to ensure that specific, identified interactions are communicated to the medical provider by the pharmacist on duty.

The facility also says it gave all nursing staff members additional training in May on detoxification protocols and on orders that include requirements pertaining to vital signs, the report says.

The Arizona Department of Health Services investigation found the medical record did not contain any documentation that consultation occurred between the physician and the clinical pharmacist regarding the interaction between Suboxone (a combination of buprenorphine and naloxone used to treat narcotic dependence) and benzodiazepines (Librium and Valium).

Sierra Tucson failed to ensure that a pharmacist “provide services related to the drug interaction between Suboxone and Diazepam, as required by hospital policy procedure,” the state report says.

On April 11, the patient rated his own depression as a 10 with 10 being the worst, the report says. The facility’s policy says that if a patient’s risk scale is 10 or greater, nurses must administer Beck Depression Inventory and Beck Hopelessness Scale tests, score them and report the findings to the medical provider. But those tests were not given to the patient as required, the state report says.

The facility fell short of its a own policy when it decreased the one-on-one observation of the patient from 24 hours to waking hours only on the night of April 12 without first completing and documenting an assessment of the patient’s risk of suicide, according to state investigators.

A Pima County Medical Examiner’s Office autopsy report says the patient was resuscitated at Sierra Tucson and then admitted to the intensive care unit of an unspecified local hospital, where his condition was listed as “grave,” and diagnostic work showed he was in multiorgan failure.

The man is the second Sierra Tucson patient to die this year. The first was a suicide on Jan. 2. In that case, a Sierra Tucson resident with a history of depression and anxiety hanged himself with a shoelace from a shower head, an autopsy report says. He died three days later at Oro Valley Hospital.

On Jan. 1, the patient had told his wife over the phone that he wanted to kill himself, state investigators found.

The woman then called the facility. Less than 24 hours later, the woman’s husband was dead. Family lawyer Bob Boatman said the family has agreed to mediation talks with Sierra Tucson prior to taking any legal action. Talks are expected to take place in January. Boatman said the family wants to remain anonymous.

The state’s report found no evidence of documentation in the patient’s medical record that he was reassessed after he told his wife he wanted to kill himself.

Sierra Tucson agreed to pay the state $2,000 after the investigation into that death, though it did not admit wrongdoing.

In September a lawsuit over the 2011 death of a patient at Sierra Tucson was settled out of court.

In that case, Dr. Kenneth Litwack, a 71-year-old Orange County, California, physician with anxiety and depression, disappeared from Sierra Tucson. Two weeks later he was found dead near the facility’s stable, about a quarter-mile from the main building. His body was so decomposed that an autopsy report could not determine how he died.

The physician’s family sued Sierra Tucson in Pinal County Superior Court, and an out-of-court settlement was reached in September.

The 31-year-old Sierra Tucson facility has been owned by CRC Health Group, a subsidiary of Boston-based Bain Capital financial services company, since 2006. CRC Health Group bills itself as the largest specialized behavioral-health-care service provider in the U.S., seeing more than 30,000 patients per day at 115 locations. Sierra Tucson is its flagship location.

The facility is on a 160-acre site at 39580 S. Lago del Oro Parkway along the Pinal-Pima county border. It has 124 beds plus 15 “acute level” beds.

It has programs to help patients with addictions, mood disorders, chronic pain, eating disorders and trauma through its “Sierra Model” of integrating therapies such as massage, yoga and acupuncture with traditional psychiatry. Most patients are in their late 30s and early 40s. A majority of patients self-pay at a cost of about $1,300 per day.

Contact reporter Stephanie Innes at sinnes@tucson.com or 573-4134.