Failure to Supervise Resident with Substance Abuse History
Summary
The facility failed to effectively supervise a resident with a history of drug abuse, leading to multiple incidents of noncompliance and ultimately the resident's death due to combined drug toxicity. The resident, a [AGE] year old female, had a history of psychoactive substance abuse, including heroin and cocaine, and was noncompliant with her psychotropic medications. Despite being informed of the facility's zero-tolerance policy for alcohol and illicit drugs, the resident repeatedly brought contraband into the facility, including vapes and THC pens, and tested positive for THC and opioids during her stay. The facility's interventions, such as smoking restrictions and counseling, were insufficient to prevent the resident from obtaining and using illicit substances. The resident's noncompliance and continued drug use were documented in multiple social service notes, which detailed incidents of the resident being found with contraband and testing positive for drugs. Despite these documented incidents, the facility did not implement new specific interventions beyond the existing care plan. The resident's substance abuse issues were discussed with her mother and the Substance Abuse Coordinator, who recommended inpatient or residential treatment, but the resident refused. The facility's failure to adequately supervise and prevent the resident from obtaining contraband ultimately led to her death. On the day of the incident, the resident was found unresponsive in her bed and was pronounced dead after unsuccessful CPR attempts. The cause of death was confirmed as combined drug toxicity involving fentanyl and acetyl despropionyl fentanyl, substances for which there were no physician orders. The facility's policies and procedures for preventing contraband and supervising residents with substance abuse disorders were not effectively implemented, resulting in the resident's ability to obtain and use illicit drugs within the facility.
Removal Plan
- A system to ensure contraband does not enter the facility and is removed from the resident will be achieved through staff education.
- Education will be provided by the Administrator, to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager.
- This education will review the facility's contraband policy and will include that residents may be asked to voluntarily empty and show the contents of their pockets at any time if reasonable suspicion exists.
- Reasonable suspicion includes frequent leaves of absence with or without facility knowledge, odors, new needle marks, and changes in resident behavior such as unexplained drowsiness, slurred speech, lack of coordination, mood changes, particularly after interaction with visitors or absences from the facility.
- Residents may be asked to voluntarily reach into concealed clothing areas and remove any items and place these items on a horizontal surface.
- Staff are instructed to have the resident hand items to the staff members or place the items on the horizontal surface.
- It is the objective of this policy that the above steps occur in plain sight of multiple witnesses (if possible) to afford appropriate protection to both the resident and the involved staff member(s).
- These steps are necessary to assure that the resident is treated with respect and dignity throughout the procedure.
- It is appropriate to ask the resident to empty his/her pockets and display their contents or roll down his/her socks.
- It is not appropriate to bring a resident into a room for a more specific search unless there is strong suspicion that the individual is attempting to bring in objects/items that may cause serious harm.
- If a more specific search is required the staff are to follow guidelines as set forth by the administrator or the administrative representative.
- This may even involve requesting professional assistance from the local police.
- Only outerwear articles of clothing including, but not limited to, jackets, coats, scarves, hats, gloves, and vests, shall be removed in plain site of staff.
- This policy recognizes that residents have attempted to hide/conceal contraband articles in undergarments in the past.
- If this appears to be the case and staff assess and suspect that these items may cause harm, staff are directed to contact the administrator or the administrative representative for instructions on how to proceed.
- The facility emphasizes treatment with dignity at all times.
- The facility reserves the right to remove locks from drawers, cabinets, closets, lockers, or any other object if there is reason to suspect that the resident possesses any item or items that may potentially harm other persons.
- The facility may choose, at its discretion, to involve drug-sniffing dogs (e.g., from a K9 company) if residents are suspected to be trafficking drugs inside the facility.
- A root cause analysis will be completed upon identification of contraband.
- Upon completion of the training, staff will sign a record of continuing education sheet to confirm their knowledge and understanding of the topic presented.
- The Director of Nursing will contact agency staff before their scheduled shift to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession.
- A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder.
- If agency nurses have any questions regarding the information presented in the staff education binder, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education.
- In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses.
- The facility has identified five staff members who are on a leave of absence/vacation.
- These staff members will be contacted by the Administrator to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession.
- The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work.
- The staff member will sign a record of education to validate their understanding of the information presented in the binder.
- If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education.
- In the Administrator's absence, the Director of Nursing will answer questions regarding the education.
- Additionally, this education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually.
- A system to prevent residents with a history of substance abuse from introducing contraband into the facility or obtaining contraband in the facility will be achieved through staff education.
- Education will be provided by the Administrator to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager.
- This education will review the facility's policy on Alcohol/Substance Use/Abuse.
- The education will review that Each resident (and/or representative) is informed that facility policy prohibits the use of alcohol without a doctor's order.
- Facility policy prohibits the use of illicit drugs.
- As a condition of residence, each person living in the facility acknowledges that he/she will not use alcohol or illicit drugs during residence in this building.
- Persons assessed with an active substance abuse problem are offered appropriate treatment and rehabilitative services.
- While this policy addresses illicit drugs and alcohol, the same standards and expectations are in place for persons with a prescription narcotic addiction.
- These individuals are also responsible for engaging in appropriate treatment to reduce/eliminate dependency on opioids.
- Persons returning from the community who present with signs and symptoms of intoxication will be evaluated by the nurse on duty or charge nurse.
- The nurse is responsible for assessing the person's physical condition and present behavior.
- The nurse will be responsible for contacting the attending physician (A.P.) if the resident is determined to be in need of medical attention and/or a decision is required regarding withholding prescribed medications.
- Documentation will be placed in the chart emphasizing signs/symptoms of intoxication/inebriation (such as smell of alcohol, behavior changes, balance/gait problems, appearance of the eyes, and change in speech pattern).
- Documentation should include the resident's own admission of alcohol/drug use.
- The facility reserves the right to have the person submit to blood/urine testing at any time if policy violation is suspected.
- Persons who are evaluated as medically unstable will be transferred for appropriate medical care.
- Follow-up interventions and treatment recommendations will be communicated to the resident/representative and documented in the medical record.
- Outside treatment sources will be utilized as appropriate.
- Residents with substance abuse disorders are expected to participate in acute/active treatment, sobriety counseling, or aftercare interventions, as appropriate to their personal situation.
- The facility has the right to implement money management interventions pursuant to federal law if substance abuse continues.
- Persons who continually jeopardize their health and the health and safety of others will be evaluated for involuntary discharge.
- Education will include instruction on how to identify which residents have a substance abuse disorder and how to locate resident-specific interventions to prevent them from obtaining contraband while in the facility.
- This information will be kept in binders at the nurse's stations.
- The binders will include a list of residents with substance abuse disorders and information on resident-centered interventions to prevent them from obtaining contraband while in the facility.
- These binders will be updated by social services weekly and with resident changes in condition.
- Upon completion of this education, staff will sign a record of continuing education to confirm their knowledge and understanding of the information presented.
- This education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually.
- The Director of Nursing will contact agency staff before their scheduled shift to review staff education regarding the prevention of residents with substance abuse disorders from introducing contraband into the facility or obtaining contraband in the facility.
- A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder.
- If agency nurses have any questions regarding the information presented in the staff education binder, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education.
- In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses.
- The facility has identified five staff members who are on a leave of absence/vacation.
- These staff members will be contacted by the Administrator to review staff education regarding the prevention of residents with substance abuse disorders from introducing contraband into the facility or obtaining contraband in the facility.
- The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work.
- The staff member will sign a record of education to validate their understanding of the information presented in the binder.
- If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education.
- In the Administrator's absence, the Director of Nursing will answer questions regarding the education.
- The procedure for developing resident-centered care plans to provide guidance to staff to prevent residents with a history of substance abuse from introducing contraband into the facility or obtaining contraband in the facility will be achieved through education provided by the Administrator to the Social Services department staff on the importance of identifying residents with substance abuse disorders and assessing their risk of introducing drugs/contraband and obtaining drugs/contraband while in the facility.
- This risk assessment is documented in the resident chart in the Social Service Initial Interview for SMI/Substance Abuse Disorder (SS) assessment.
- This risk assessment must be used by the social services staff to develop a resident-centered care plan to address the potential risks of the resident introducing drugs/contraband into the facility and obtaining contraband/drugs while in the facility.
- Care plan interventions will be based on the resident's personal risk factors and coping mechanisms and may include but are not limited to efforts outlined in the facility policy for Alcohol/Substance Use/Abuse such as outside treatment services, acute/active treatment, sobriety counseling, or aftercare interventions.
- The effectiveness of the care plan must be reviewed quarterly and with changes in condition and updated as indicated.
- A binder will be placed at each nurse's station with a list of residents with substance abuse disorders as well as information on the resident-centered interventions for preventing them from obtaining contraband while in the facility.
- These binders will be updated by the social services department weekly and with resident changes in condition.
- Upon completion of this education, social services staff will sign a record of continuing education to confirm their understanding and knowledge of the topics presented.
- This education will be presented to new hire social services staff upon hire and will be reviewed with all social services staff annually.
- Agency staff is not utilized in the social services department.
- There are currently no social services staff on leave of absence or vacation.
- There have been no updates to facility policies.
- A system to supervise residents from obtaining contraband and from having or obtaining illicit drugs in the facility will be achieved through staff education.
- The Administrator will educate staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and business office manager on the facility standard for providing adequate supervision for residents with substance abuse disorders to prevent them from obtaining contraband/ drugs.
- This education includes a review of the facility policy for safety and supervision which focuses on ensuring a facility-oriented approach to safety to address risks for groups of residents including residents with substance abuse disorders/history.
- Education will discuss the importance of identifying safety risks and environmental hazards on an ongoing basis.
- Staff will be educated that resident supervision is a core component of resident safety and that the type and frequency of supervision are determined by the individual resident's needs.
- Staff must intervene immediately whenever an unfavorable event between residents, staff, or visitors is noticed.
- Staff must decrease safety hazards as much as possible and provide redirection when necessary.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to ensure effective fall alarms and supervision: two residents had Smart Caregiver monitoring devices set to LOW volume, and one resident's bed alarm did not alert staff before the resident was found on the floor after an unwitnessed fall. One resident had dementia, osteoporosis, prior TIA, and cognitive impairment and was fully dependent on staff, while staff also found that a second resident's bed and recliner alarms did not activate properly during testing.
Failure to assess the safety of perimeter mattresses for two residents. Both residents had severely impaired cognition and significant mobility limitations, and both care plans included use of a perimeter mattress to define the edges of the bed. However, their Mobility, Physical Device, and Fall Risk assessments lacked documentation of a perimeter/defined edge mattress assessment. Staff interviews showed inconsistent understanding of the required order, IDT review, engineering review, and safety assessment before use.
Improper Mechanical Lift Transfers: A resident with dementia, spinal cord dysfunction, and dependence for transfers was supposed to be moved with a full-body mechanical lift and two staff members, but a TMA stated she transferred the resident alone. The resident reported that staff sometimes used only one person for lift transfers because of staffing shortages, while other staff and the DON stated this was unsafe and against policy.
Two residents were involved in accident-hazard deficiencies. One resident with cancer, PVD, and Alzheimer’s disease was observed in a wheelchair with feet extending past short footrests, with the lower legs resting against the hard footrests despite a care plan entry for padding. Another resident with dementia and a hx of falls had an unwitnessed fall, but ordered orthostatic BP monitoring was not completed accurately and staff reported no post-fall PT referral was received.
A resident was given a new electric wheelchair without a prior therapy assessment and could not stop the chair, causing it to strike a bed frame and resulting in a leg laceration, tibia/fibula fractures, and a syncopal episode from blood loss. Another resident with cognitive impairment and high fall risk continued to self-transfer and fall, but the care plan was not updated with new fall interventions after repeated incidents.
A CNA used a Hoyer lift alone to weigh one resident, and another CNA was observed using a Hoyer lift alone to weigh a second resident. One resident’s care plan called for a 2-assist Hoyer lift, and the facility’s lift competency checklist and policy both required two caregivers for mechanical lift use; the DON and Director of Therapy also stated that two staff members are always required.
Failure to Ensure Effective Fall Alarms and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for two residents who were reviewed for fall precautions. One resident had diagnoses including unspecified dementia, age-related osteoporosis, a history of transient ischemic attack, and cognitive impairment, and was described by the POA as weak, bedbound, and unable to participate in physical therapy after a prior right femur fracture. The resident was completely dependent on staff for eating, hygiene, mobility, and toileting, and the care plan included a bed alarm per orders. The resident was found on the floor next to the bed after an unwitnessed fall. The POA reported receiving a call from the facility that the resident had been found on the floor and was not injured, and stated the resident frequently forgot to ask for help and had tried to get up without assistance before. A nurse stated the bed alarm was not heard when the resident fell, and the facility was unable to provide evidence that the bed alarm functioned as intended or alerted staff before the resident was found on the floor. The event report identified the fall as unwitnessed and did not indicate that a bed alarm alerted staff. The facility also failed to ensure the Smart Caregiver sensor pad monitoring system used for another resident was functioning properly and set at an audible volume. Two Smart Caregiver monitor boxes at the nurses' station for that resident's bed and recliner were observed set to LOW volume, and the chime settings faced the back wall of the desk. When a CNA tested the recliner alarm from the resident's room, the monitor at the nurses' station did not illuminate or sound an alert on either attempt. The CNA changed the batteries but did not retest the device, and both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall training on operation or testing of the devices. The facility director stated the facility did not perform preventive maintenance on the devices and relied on staff to ensure they functioned properly.
Failure to Assess Safety of Perimeter Mattresses
Penalty
Summary
The facility failed to ensure that 2 residents with perimeter mattresses were assessed for safety. One resident had a significant change MDS showing severely impaired cognition, dementia, reduced mobility, muscle weakness, and need for assistance with bed mobility, sitting, standing, and transfers. That resident’s care plan identified limited physical mobility related to dementia with mood disturbance and anxiety, a genetic muscle disorder, spinal stenosis, and osteoarthritis, and included use of a perimeter mattress to help find the edges of the bed for bed mobility. However, the resident’s Mobility, Physical Device, and Fall Risk assessment lacked documentation of an assessment for a perimeter/defined edge mattress. The second resident’s annual MDS showed severely impaired cognition, dementia, multiple sclerosis, repeated falls, and need for partial to moderate assistance with bed mobility. The care plan identified limited physical mobility related to weakness, falls, incontinence, hypertension, renal disease, dementia, MS, depression, and delusional disorder, and included use of a bariatric sized bed with a perimeter mattress to define the edges of the bed. That resident’s Mobility Physical Device and Fall Risk assessment also lacked documentation of an assessment for a perimeter/defined edge mattress. During observation, the resident was in bed asleep with a perimeter mattress. Staff interviews showed differing understanding of whether a physician order, assessment, IDT review, engineering review, and safety assessment were required before use of a perimeter mattress, and the DON confirmed both residents’ most recent assessments lacked documentation of a perimeter/defined edge mattress assessment.
Improper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure transfers were performed according to R24’s assessed needs, care plan interventions, and facility policy. R24’s records showed she had diagnoses including non-traumatic spinal cord dysfunction, diabetes, dementia, depression, heart failure, and asthma. She was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had care plan directions for assistance with transfers using a full-body mechanical lift and two staff members. During interviews, a TMA stated she transferred R24 with the full-body mechanical lift by herself because R24 needed to use the bathroom and she felt the transfer was safe. R24 stated staff sometimes transferred her with only one staff member and said they told her there was not enough staff. Other staff interviewed stated transfers with the full-body mechanical lift using one staff member were unsafe and should not occur. The facility policy for using a mechanical lift stated that at least two trained associates are needed to safely move a resident with a mechanical full-body floor-based lift or ceiling/overhead full-body lift.
Unsafe Wheelchair Fit and Incomplete Post-Fall Monitoring
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. Resident 27 was readmitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer's disease and was sometimes able to make needs known. On multiple observations, Resident 27 was seated in a slightly tilted back wheelchair with feet extending beyond the footrests, and the back of the lower legs rested against the hard footrests above the ankle/heel area. A pillow was observed either on the floor or behind the legs rather than padding the footrests. The focused care plan for skin integrity included padding to wheelchair footrests, and staff interviews confirmed the footrests were too short and needed adjustment or replacement, but staff had not notified therapy or otherwise addressed the wheelchair fit. Resident 50 was admitted with diagnoses including dementia, history of falls, and UTI and was sometimes able to make needs known. The care plan identified the resident as at risk for falls. After an unwitnessed fall in the 300 hallway, the incident investigation added interventions to monitor orthostatic blood pressures and refer to physical therapy. However, the record showed an orthostatic blood pressure order on 05/20/2026 was not completed, and subsequent orthostatic blood pressures recorded the same blood pressure and pulse for all three positions on 05/22/2026, 05/23/2026, and 05/24/2026. Staff later stated they had not received a post-fall therapy referral, and the DNS stated the resident should have had orthostatic blood pressures taken accurately to rule out orthostatic hypotension.
Failure to assess electric wheelchair use and update fall interventions
Penalty
Summary
The facility failed to comprehensively assess a resident for the use of an electric wheelchair and failed to develop new interventions to reduce fall risk for another resident. The report states that the facility’s policies required a device evaluation before an electric wheelchair was initiated, resident education and consent, and an updated service plan identifying device use and other interventions. The fall management policy required individualized care plan updates, a systematic review after each fall, identification of root cause, and review of prior interventions when new interventions were implemented. Resident 73 was admitted with weakness and lymphedema and had an above-the-knee left leg amputation, requiring assistance with bed mobility, transfers, and locomotion. The resident’s record showed cognitive intactness, lower extremity impairment, supervision or touch assistance for bed-to-chair transfers, and use of a manual wheelchair. On 4/17/26, a newly issued electric wheelchair was delivered and the resident was assisted into it. The resident reported that the representative showed how the chair worked but not enough, and that the resident did not know how to stop it. The resident then returned to the room, could not stop the chair, and the chair continued forward into the bed, causing the resident’s right leg to strike the metal bed frame. The resident sustained a five-centimeter laceration to the right anterior lower leg, fractures of the right tibia and fibula, and a brief syncopal episode secondary to blood loss. The resident also received an anticoagulant, which contributed to significant bleeding. The clinical record contained no evidence that the resident had been assessed to safely operate the electric wheelchair before use. Resident 3 was admitted with a right total hip replacement with deep hardware removal and post-traumatic osteoarthritis of the right hip. The resident had a high fall risk on Morse Fall Scale assessments, cognitive impairment on OT evaluation, and a PT evaluation showing a score of zero on the Short Physical Performance Battery, indicating high fall risk and increased risk of mobility disability. The resident fell on 3/31/26 after getting up independently and sustained a right femur fracture requiring surgical repair, and fell again on 5/12/26 after getting up independently and sustained a skin tear to the right elbow. The care plan identified fall risk and included reminders to use the call light, non-skid socks, and one-person assistance for toileting and transfers, but revisions to the care plan did not add new or amended fall prevention interventions. Staff statements indicated the resident continued to self-transfer and toilet without assistance, staff believed the resident was independent, and the existing fall prevention interventions were ineffective.
Unsafe One-Person Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure safe use of a mechanical lift for 2 of 3 residents reviewed for accidents. During an observation on 6/2/2026 at 8:42 AM, Resident #4 was lying on his bed on top of a Hoyer pad while CNA Staff K stood on the right side of the bed with a mechanical lift; the lift hand bags were observed over the resident, and no other staff member was in the room. Staff K stated that he was weighing Resident #4 and that normally only one person uses the Hoyer lift for weights, although the resident’s care plan documented a Hoyer lift with 2 assist. On 6/4/2026 at 10:15 AM, CNA Staff D was observed using a Hoyer lift alone to obtain Resident #13’s weight, with the resident lifted approximately 12 inches off the mattress in the sling and no other staff present. Staff D stated that he was performing weekly weights and most of the time did the weights using the Hoyer lift by himself. Resident #13’s MDS Section GG coded the resident as dependent, and the facility’s mechanical lift competency checklist stated that two caregivers are present, while the facility policy for using a mechanical lifting device stated that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The DON and Director of Therapy both stated that a mechanical lift should always be used by two staff members.
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