Failure to Conduct Contraband Search Results in Resident Overdose and Injury
Penalty
Summary
The facility failed to follow its policy regarding contraband searches for a resident with a known history of substance abuse. The resident had previously been found unresponsive with a rolled-up dollar bill containing a white powdery substance, and after this incident, restrictions were put in place requiring that the resident only go out with a responsible party and that his belongings be searched upon return from outings. Despite these measures, on a subsequent occasion, the resident was allowed to leave the facility with a relative and upon return, there is no evidence that the required contraband search was conducted by social services as per facility policy. Shortly after returning from the outing, the resident was found unresponsive on the floor of another resident's room, with a laceration to the right eyebrow. Staff assessed the resident, administered Narcan, and called 911 for transport to the emergency room. During this time, a bag containing a white powdery substance was found in the resident's pocket. The resident was hospitalized with a diagnosis of opioid overdose and a laceration. Interviews with staff revealed that there was confusion and lack of communication regarding who was responsible for searching the resident upon return from outings. The social services director was not present when the resident returned and was not informed of the resident's return, and it was unclear if any staff conducted the required search. The facility's policy allows for searches when there is reasonable suspicion of contraband, and in this case, the policy was not followed, resulting in the resident's overdose and injury.