Failure to Protect Resident from Abuse Involving Unprescribed Methadone
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse when a male resident with a history of drug abuse, heart failure, stroke, and depression was found unresponsive in his room and subsequently tested positive for methadone, a medication for which he did not have a physician's order. The resident required emergency intervention, including Narcan administration, and was transported to the hospital where he was diagnosed with hypoxia likely due to acute-on-chronic systolic heart failure. Hospital records confirmed the presence of methadone and opiates in his system, and the resident later alleged that he had received methadone from a staff member, though he refused to identify the individual involved. Review of the resident's care plan and medication orders confirmed that methadone was not prescribed or available to him through legitimate medical channels within the facility. Staff interviews indicated that the resident had not signed out of the facility, and there was no evidence of him obtaining methadone from outside sources. Nursing staff reported finding the resident in respiratory distress and unresponsive, with no prior indication of nonprescription drug use or possession. The resident's care plan was updated to reflect his drug abuse history only after the incident, and interventions such as education on the facility's drug policy and psychological support were documented post-event. Despite the resident's initial admission to a state investigator that he received methadone from a staff member, he later denied this to facility staff, administration, and police. The facility's policies on abuse prevention and drug use were in place, but the investigation revealed that the required immediate reporting and thorough investigation of the incident were not initiated until after the state investigator's involvement. Prior to the identification of Immediate Jeopardy, the only evidence provided by the facility included staff in-services and care plan updates, with no documentation of medication audits, safe surveys, or timely self-reporting to the state agency.