Failure to Update Care Plans After Drug Use Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents following incidents involving illegal drug use. Both residents had documented histories of behavioral health issues, including bipolar disorder and stimulant use, and were found in possession of and attempting to smoke methamphetamine within the facility. Despite these incidents, their care plans were not updated to reflect substance abuse or drug-seeking behaviors, nor were new interventions or measurable objectives added to address these new risks. For the first resident, records showed that after admission, the baseline care plan only addressed general behavioral needs and adjustment to the facility, with no mention of substance abuse. Progress notes documented that the resident sought methamphetamine from others and was later found with a suspicious substance and paraphernalia in another resident's room. The incident was reported to facility leadership and law enforcement, but the comprehensive care plan remained incomplete and did not address the substance abuse incident. The second resident, who also had a history of behavioral symptoms and nicotine dependency, was found in a similar situation with the first resident, attempting to smoke methamphetamine. The care plan for this resident focused on previous behavioral issues such as leaving the facility without signing out and not following the smoking policy, but did not include any interventions or objectives related to substance abuse following the incident. Facility policy required care plans to be updated with measurable objectives and timeframes after such events, but this was not done for either resident.