Failure to Prevent Hazards and Provide Adequate Supervision for Residents with SUD and Mobility Risks
Penalty
Summary
The facility failed to keep residents free from hazards and provide adequate supervision, particularly for residents with a known history of substance use disorder (SUD) and those at risk for accidents during transfers. One resident with a history of polysubstance use was admitted and later experienced two critical incidents: first, being found unresponsive in the facility's parking lot due to a suspected opioid overdose, and second, being found deceased in their bathroom with drug paraphernalia present. Despite these events, there was no evidence that the resident's care plan addressed their history of substance use, nor was there any indication that monitoring for opioid use was initiated after the resident returned from the hospital following the first overdose. Staff interviews revealed a lack of knowledge and training regarding SUD. Multiple staff members, including CNAs, LPNs, and housekeepers, reported not receiving education on identifying signs and symptoms of drug use, monitoring residents with SUD, or handling drug paraphernalia. The Social Services Director confirmed that training on SUD was only provided to licensed nursing staff and not to CNAs or other direct care staff. Additionally, the facility did not update care plans or implement monitoring for other residents with a history of SUD, as identified by the Social Services Director. In another case, a resident with hemiplegia and severe cognitive impairment required extensive assistance for car transfers and had a witnessed fall during a transfer with a family member. Although a physical therapy referral was made, neither the resident nor the family member received education or training on safe car transfers following the incident. Staff were unaware that the resident continued to go out with the family member after the fall, and no further interventions were implemented to address the risk of future accidents.
Removal Plan
- Review all residents' records to identify other residents with history of or active substance use disorder.
- Identify residents with active, suspected, or history of substance use and list them in a binder at the nursing stations. Place a sticker on the residents' name plates outside their rooms to alert staff of potential hazards associated with active substance use disorder.
- Offer substance use treatment services to residents identified with history of or active substance use disorder.
- Assess residents identified with history of or active substance use disorder upon return from independent offsite outing for suspected substance use.
- Generate an incident report and notify law enforcement if required for residents assessed upon return from independent offsite outing or identified as active substance use.
- Educate staff, including temporary or agency staff, on the location of the binder with residents identified with suspected or history of substance use disorder.
- In-service staff, including temporary or agency staff, on substance use disorder, signs of abuse related to drug use, actions to take if active use is suspected, reporting suspected drug paraphernalia, and facility policy on resident possession and use of illegal substances.
- Place residents identified with drug paraphernalia or signs/symptoms of active drug use on alert monitoring, notify MD, place POC task to alert CNA for increased monitoring for drug paraphernalia, notify law enforcement if required, generate an incident report, and complete resident assessment.