Failure to Develop Care Plan for Resident's Methamphetamine Use
Penalty
Summary
The facility failed to develop and implement a care plan to address a resident's use of methamphetamine, despite documented evidence of substance abuse. The resident, who was capable of making healthcare decisions, had a history of methamphetamine abuse noted in the medical record and tested positive for methamphetamine during a drug screen. Additionally, facility staff discovered a bag containing a substance identified as methamphetamine under the resident's pillow, which was confirmed by local law enforcement. Interviews and record reviews with the MDS nurse and the DON confirmed that there was no care plan in place to manage the resident's illegal drug use. The facility's policy required comprehensive, person-centered care planning to address all health, safety, psychosocial, and behavioral needs, but this was not followed in the case of the resident's substance abuse. The lack of a care plan meant that there were no interventions or monitoring measures documented to address the resident's drug use.