Failure to Prevent Ingestion of Illegal Substance
Penalty
Summary
The facility failed to implement effective safety measures to prevent a resident from ingesting an illegal substance. Resident 25, who has a history of schizoaffective disorder, bipolar type, chronic pain, and polysubstance use disorder, was admitted to the facility and was cognitively intact with a BIMS score of 15. On December 9, 2024, the resident exhibited symptoms such as slurred speech and tremors, which worsened by the early hours of December 10, 2024, leading to a transfer to the emergency room. It was discovered that a visitor had given the resident a marijuana edible gummy, resulting in an overdose event. The resident's care plan did not include interventions or a plan to prevent the recurrence of consuming nonprescribed medications. Additionally, there was no documentation of education provided to the resident regarding the risks of ingesting nonprescribed substances. The Director of Nursing confirmed that no interventions or educational measures had been implemented to prevent the resident from being provided with or consuming nonprescribed medications.
Plan Of Correction
1. Resident 25 was educated on risks of consumption of non-prescription medications and care plan was updated with interventions to prevent recurrence. 2. New admissions will be educated on risks of consumption of non-prescription medications. The outside medication policy was revised to include illegal substances that are prohibited from entrance to the facility. This policy will be sent to all residents and responsible parties to ensure compliance. 3. Licensed Nursing staff were re-educated on providing risk education to residents following non-compliant episodes and applying effective interventions to care plans post incident, as well as the changes and revisions to the new outside medication policy. The DON will review incident reports for effective intervention implementation and education. 4. The DON or designee will conduct an audit of incidents weekly for 4 weeks, then monthly for 2 months to ensure effective interventions are care planned and necessary education is completed. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.