Failure to Prevent Resident Possession of Contraband Medications and Alcohol
Penalty
Summary
The facility failed to provide a safe environment for a resident by not preventing the possession of a bottle of alcoholic beverage and multiple prescription medication bottles from an outside pharmacy, despite having a policy prohibiting such items. The resident, who had diagnoses including depression, anxiety, and borderline personality disorder, was admitted with cognitive intactness and required some assistance with daily activities. The facility's policy clearly stated that restricted items, including non-facility prescribed medications and alcohol, were not allowed, and staff were responsible for monitoring for such items. On the day of the incident, the resident was found unresponsive in their room by an LVN, with opened containers of doxepin and ondansetron at the bedside, both labeled from an outside pharmacy. Further investigation by local police and facility staff revealed additional bottles of prescription medications and a bottle of wine among the resident's belongings. Interviews with staff confirmed that medications from outside pharmacies were not permitted and that the facility's procedures for checking residents' belongings for contraband were not followed. Staff acknowledged that the resident was able to bring in alcohol and medications without detection, which was against facility policy. Medical records from the hospital indicated that the resident was admitted with altered mental status, a Glasgow Coma Scale of 3, and was intubated for a suspected intentional overdose of tricyclic antidepressants and possibly clonazepam. The resident remained in intensive care before being discharged home. The presence of unauthorized medications and alcohol in the resident's possession, and the lack of adequate supervision and enforcement of the facility's contraband policy, directly led to the resident's medical emergency.