Failure to Prevent Resident Drug Use and Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with multiple complex medical and behavioral diagnoses, including COPD, multiple sclerosis, bipolar disorder, and legal blindness. The resident had a moderate cognitive impairment and required partial to moderate assistance with most activities of daily living. Despite being on parole for drug use and a sex offense, and after staff were informed by the resident's parole officer that he was bringing drugs into the building to sell to other residents, the facility did not implement effective interventions to prevent further incidents. The resident was found exhibiting signs of an overdose, including weakness, limpness, pinpoint pupils, confusion, and difficulty talking, and was subsequently transported to the hospital, where he tested positive for marijuana. Prior to this event, the resident had failed drug screenings, and the facility was aware of ongoing concerns about drug use among residents, as reported by multiple residents and staff. The facility did not have a care plan addressing the resident's behavior related to substance abuse, and there was no evidence of a thorough investigation or reporting to the state agency when drug use was suspected or confirmed. Interviews with residents and staff revealed that the smell of marijuana and reports of drug use were common, particularly during smoke breaks and in resident rooms. The Administrator and DON acknowledged awareness of these issues but did not take sufficient action to investigate, report, or prevent the introduction and use of nonprescription drugs within the facility. The facility's policy prohibited illegal drug use, but it was not effectively enforced, and staff were not in-serviced on recognizing or reporting signs and symptoms of drug use prior to the incident.
Removal Plan
- Resident #2 was assessed for signs or symptoms of drug use. MD was notified. Resident was drug tested.
- All residents will be in-serviced on the facility policy regarding illegal drug use.
- All residents will be assessed upon return from any leave from the facility for signs and symptoms of illegal drug use to include limpness on both sides of body, pinpoint pupils, confusion, and difficulty talking.
- All nursing staff will be in-serviced to perform and document the assessment upon return and if any signs and symptoms are noted the Administrator and DON will be notified, and the facility will follow the illegal drug use policy.
- The DON/designee will monitor the documentation for each resident return to ensure the assessments are complete.
- Resident is being discharged pending acceptance.
- The DON/designee will monitor the effectiveness of assessments completed of residents.
- QAPI meeting will be held and findings will be discussed.
- A pre/posttest will be completed by staff on signs/symptoms of drug use and ongoing.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.