Failure to Develop Care Plan for Opioid Overdose
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for a resident who experienced an opioid overdose. Resident #55, who had diagnoses including Delusional Disorder, Bi-Polar Disorder, and Alcohol Abuse, was transferred to the hospital due to unresponsiveness and was readmitted with a diagnosis of opioid overdose. Despite the facility's policy requiring Naloxone availability and standing orders for its administration, there was no documented evidence of a care plan with appropriate interventions to prevent further opioid overdoses. Interviews revealed that the Minimum Data Set Coordinator and the Director of Nursing Services acknowledged the absence of a care plan addressing the opioid overdose. The Minimum Data Set Coordinator stated that they or the admission nurse could have initiated such a care plan, and the Director of Nursing Services confirmed that the responsibility lay with the Minimum Data Set Coordinator, with Registered Nurse Supervisors as a backup. The lack of a care plan specifically addressing the opioid overdose was identified as a deficiency during the survey.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction to address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F656. Resident #55 care plan was updated on 2/10/2025 by MDS Coordinator to include [DIAGNOSES REDACTED]. All residents on opioids and/or have a history of opioid overdose have the potential to be affected by this alleged deficient practice. A full house audit was conducted on all residents by MDS Coordinator/DON on 2/27/2025 to ensure that residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression have a care plan that addresses their risk for opioid overdose and have appropriate goals and interventions to prevent potential opioid overdose. Any negative findings were immediately corrected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Comprehensive Care Plan was reviewed by MDS Coordinator/ DON/ Social Worker, Coordinator/DON/social worker. The DON/MDS Coordinator educated the nursing staff and IDT on 2/25/2025 about “Comprehensive Care Plans” with emphasis on developing a person-centered care plan for those residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression, with appropriate goals and interventions to prevent further potential opioid overdose. Care plans were immediately updated to reflect an accurate, person-centered plan of care for the residents based upon the residents assessed condition and needs, if required. Staff were reminded of the potential consequences to both the residents and staff if the policy is not followed. Any staff found responsible for the deficient practice will be referred to the DON for counseling. An audit was conducted on all residents by MDS Coordinator /DON on 2/27/2025 to ensure that residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression have a care plan that accurately reflects their physical and mental health needs and assures their needs are addressed and met. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The MDS Coordinator /DON/Designee will audit 5 resident care plans x 4 weeks, then 5 resident care plans monthly x 3 months to ensure that residents with moderate to high risk index for opioid overdose or serious opioid-induced respiratory depression have a person-centered care plan addressing potential for opioid overdose with appropriate goals and interventions to prevent further potential opioid overdose. Any adverse findings will be immediately corrected. Audit findings will be presented to the QA Committee monthly meetings x 6 months. The results of these audits will be reviewed in the monthly QA Committee monthly meetings for 6 months or until 100% compliance is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5. The date for correction and the title of the person responsible for correction of each deficiency: DON is responsible for the compliance by 03/10/2025.