Failure to Monitor and Care Plan for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure that a resident with a known Substance Use Disorder (SUD) received adequate monitoring and supervision to prevent avoidable accidents and hazards. The resident, who had a history of methamphetamine abuse and multiple complex medical conditions including osteomyelitis, end stage renal disease, diabetes, heart failure, and paraplegia, was allowed to leave the facility on pass frequently. Upon return, there was no documented assessment or evaluation for signs of drug use or overdose, and staff interviews confirmed that monitoring for drug use was not consistently performed. Documentation of the resident's departures and returns was incomplete, with no records in nursing progress notes or sign-in/sign-out logs regarding the resident's condition upon return to the facility. Nursing and other facility staff had not received training or education on how to manage emergencies related to SUD, including recognizing signs and symptoms of drug intoxication or overdose. Multiple staff members, including CNAs, nurses, and the Social Service Director, confirmed they had not been trained in behavioral management or emergency response for residents with SUD. The Director of Nursing acknowledged that such training had not occurred, despite the resident's known history of drug use and behavioral outbursts, including aggression and altercations with other residents and staff. Additionally, the facility did not develop a care plan specific to the resident's SUD, with no documented goals or interventions to address the risks associated with substance abuse, such as potential accidents, hazards, or overdose. The Minimum Data Set Nurse confirmed that a care plan addressing SUD should have been developed but was not present in the resident's records. These failures were contrary to the facility's own policy requiring assessment and care planning for resident-specific safety risks.