Failure to Implement Abuse and Drug Prevention Policies Resulting in Resident Overdose
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, specifically in the case of one resident who was found unresponsive and later tested positive for Methadone, a medication for which he did not have a physician's order. The resident, who had a history of drug and alcohol abuse, was admitted with multiple medical conditions including acute systolic heart failure, stroke, and major depressive disorder. On the day of the incident, the resident was found in respiratory distress and was only responsive to sternal rub, with an oxygen saturation of 47% on room air. He was transported to the hospital, where he was diagnosed with hypoxia likely due to acute-on-chronic systolic heart failure, and laboratory results revealed the presence of Methadone and opiates in his system. Upon interview, the resident stated that he had received Methadone from a staff member, although he refused to identify the individual and later denied the incident during subsequent interviews. Facility records showed that the resident had not signed out to leave the facility, and there was no physician order for Methadone in his medication records. Staff interviews indicated that they were unaware of the resident having access to nonprescription drugs or staff providing such substances. The facility's policies required prompt investigation and reporting of abuse, neglect, and drug-related incidents, but there was a delay in initiating a provider investigation and submitting a self-report to the state agency. The facility's leadership, including the DON and Administrator, did not immediately act upon learning of the Methadone finding in the resident's hospital records. The investigation and required notifications were not initiated until after the state investigator became involved. There was no evidence provided of medication audits, safe surveys, or timely reporting to the state agency prior to the identification of Immediate Jeopardy. This lapse in following established policies and procedures resulted in a deficiency related to the facility's failure to protect residents from abuse and to ensure a safe, drug-free environment.
Removal Plan
- Alleged employee suspended pending investigation
- Attending Physicians was notified of the incident involving the resident
- Trauma screen was completed
- Police notified
- Resident referred to Deer OAKS for psychological assessment
- Care plans updated
- Reviewed out on pass
- Reviewed advance entry for visitors
- Reviewed facility medications for use of methadone
- Completed care plan conference with residents
- Resident seen by psychologist
- Drug abuse contract and policy discussed with residents and signed
- Staff in-service on facility drug policy, identifying intoxicated residents, Narcan administration, and will be completed. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff who are not in-serviced for any reason will receive it before the start of the shift
- Abuse and neglect in-service started and will be completed. All staff in services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee
- 1:1 in-service conducted for DON and Administrator on Abuse and Neglect Policy. In-service conducted by RDO and RNC
- Staff and resident questionnaires
- Safe surveys
- Offered drug rehab services to resident
- Audit of all residents who have a drug history or potential for drug use and have completed the drug policy acknowledgement form. This will be ongoing to ensure all new admits and changes are made where necessary. This will be conducted by the DON or Designee
- Appropriate interventions are being put in place as needed
- All staff were re-educated on identifying intoxicated residents and the resident drug and alcohol abuse policy. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee
- Staff (nurses) in-service on facility drug policy, identifying intoxicated residents, Narcan administration, abuse, and neglect. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee
- The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted and ongoing
- The Administrator/DON will review the effectiveness of this daily and weekly, then monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discovery
- The Medical Director met with the Interdisciplinary team and conducted an Ad HOC QAPI regarding resident drug use. The Medical Director was notified about the immediate Jeopardy, the Plan of removal was reviewed and accepted by Medical Director
- An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal
- The Director of Nursing and Administrator will be responsible for the implementation of Process