Failure to Investigate and Report Alleged Drug Diversion and Resident Overdose
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated and did not prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for one resident. Specifically, the facility did not implement its abuse, neglect, and exploitation policy or investigate suspected or alleged abuse when a resident alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for methadone, for which he did not have a physician's order. This failure was identified through observation, interviews, and record review. The resident involved had a history of drug and alcohol abuse, major depressive disorder, and other significant medical conditions, including heart failure and stroke. He was found unresponsive in his room, with low oxygen saturation, and was transferred to the hospital, where he responded to Narcan administration and tested positive for methadone and opiates. There was no evidence in facility records that the resident had an order for methadone or that he had left the facility to obtain it elsewhere. The resident later stated he received methadone from a staff member but refused to identify the individual and subsequently denied the incident in later interviews. Despite the resident's allegation and the positive drug test, the facility did not immediately initiate a thorough investigation or report the incident to the state agency as required by policy. Initial actions were limited to staff in-services and care plan updates, with no evidence of medication audits, interviews, or other investigative steps until prompted by external parties. The delay in investigation and reporting was confirmed through interviews with facility leadership and regional managers, who indicated that a provider investigation and self-report were only initiated after the issue was brought to their attention by a state investigator.