Failure to Assess and Care Plan for Residents with Substance Use Disorder
Penalty
Summary
The facility failed to adequately assess residents with a history of Substance Use Disorder (SUD) for associated risks, develop comprehensive individualized care plans, and implement interventions to ensure their safety. For five sampled residents with SUD, the facility did not consistently perform or document risk assessments, provide education on facility policies regarding substance use, or increase monitoring as care planned. In several cases, residents with known SUD histories were not given individualized care plans addressing their specific risks, and interventions such as increased monitoring or education were either not implemented or not documented. One resident with a history of polysubstance abuse and homelessness experienced repeated late-night visits from outsiders and was later found unresponsive in their room alongside a visitor, requiring emergency intervention with Narcan and hospitalization. Despite care plan interventions calling for increased monitoring and assessment, there was no documentation that these actions were carried out. Another resident with opioid abuse and polysubstance use was administered Narcan after being found drowsy and unresponsive, but their care plan did not address SUD-related risks, and there was no evidence of education on facility policies regarding substance use. Other residents with SUD histories were noted to leave the facility unsupervised, associate with individuals known for drug use, and return with signs of substance use, yet their care plans lacked specific interventions for SUD risk management. Staff interviews revealed a lack of standardized assessment tools for SUD, inconsistent care planning practices, and failure to educate residents on facility policies regarding substance use. Admission staff did not review facility rules or policies on drug use with residents, and there was no documentation that residents were informed of expectations regarding substance use and possession of illegal substances. The facility's own policy required individualized, resident-centered interventions for SUD, but these were not consistently implemented or documented for the affected residents.