Failure to Revise Care Plans After Positive Drug Screens
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents after significant changes in their condition were identified. Both residents were sent to the hospital for altered mental status and subsequently tested positive for substances not prescribed to them. Despite these findings, neither resident had their care plan updated to address substance abuse or the new information from their hospitalizations. One resident, a male with hepatic encephalopathy, alcohol cirrhosis, and other significant diagnoses, was admitted with moderate cognitive impairment. He was sent to the hospital for altered mental status, where a urine drug screen was positive for benzodiazepines and THC, neither of which were prescribed. The care plan did not reflect any interventions or monitoring related to substance abuse, and staff interviews confirmed that this information was not incorporated into his care planning. The second resident, a female with paraplegia and chronic respiratory conditions, was also sent to the hospital for altered mental status. Hospital records indicated a THC overdose, with a positive urine drug screen for THC. Like the first resident, her care plan did not address substance use, and staff interviews revealed that the hospital report was not reviewed or acted upon in terms of care planning. The lack of care plan revision was acknowledged by facility leadership and nursing staff.