Failure to Prevent and Investigate Drug-Related Incidents
Penalty
Summary
The facility failed to ensure the safety of its residents by not implementing effective interventions to prevent illicit drugs from entering the facility and to prevent drug-related incidents among residents. Despite being aware that a resident had a history of drug use and overdose, the facility did not take adequate measures to monitor or restrict access to substances, resulting in multiple incidents where the resident was found unresponsive or in distress and required hospitalization for drug-related diagnoses. The facility also did not conduct thorough investigations into these incidents, and staff were uncertain about the source of the drugs or whether the resident had used substances within the facility. On several occasions, the resident was found in a compromised state, such as being unresponsive in a wheelchair, and required emergency intervention and transfer to the hospital. Documentation and interviews revealed that staff observed symptoms consistent with drug overdose, administered emergency medications, and called for emergency services. However, there was a lack of consistent incident reporting, and some staff did not complete incident reports or investigations, believing the incidents may have been related to the resident's activities outside the facility. There was also confusion among staff regarding the requirements for reporting such incidents to regulatory agencies. The facility's policies acknowledged an increase in residents with a history of drug use and outlined the need for assessment and follow-up treatment if drug use was suspected. However, the facility did not follow its own protocols for incident reporting and failed to notify the appropriate state and local authorities about the drug-related incidents. Staff interviews indicated uncertainty about their ability to search residents or prevent drugs from entering the facility, and there was a lack of clear action to investigate or address the repeated incidents involving the resident.
Plan Of Correction
F 000 F 000 *Free of Accident Hazards/Supervision/Devices ELEMENT ONE: CORRECTIVE ACTION: - The U.S. FOIA (b) (6) [R] and [R] received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for [R] and [R] and the requirements to report these incidents to the DOH [R] /LTCO or [R]. All nursing staff was re-educated on the illicit drug use policy which includes reporting overdoses to the New Jersey Department of Health and police on 5/9/25. The Director of Nursing re-investigated the incidents involving Resident #6 on [R]. An audit was conducted to identify all residents with a history of [R] and/or [R] on [R]. The Social Worker met with all residents with a history of [R] and/or [R] to educate residents on the medical risks of [R] use and [R] involvement. All residents were notified that upon return from out on pass they will be subjected to a search by nursing and/or security. Upon any suspicion of [R], a room search will be conducted by nursing/security. All residents suspicious of [R] will be required to open any incoming packages/deliveries in the presence of a staff member of nursing or security. If resident is found to be in possession of [R] and/or if an [R] occurs, the resident will be subject to a possible 30-day discharge notice from the facility, and/or revoking of facility out on pass privileges on 5/9/25. The Social Worker provided education to all residents with a history of [R] use and/or [R] on the availability of [R] programs on 5/9/25. The Social Worker met with Resident #6 to educate the resident on the availability of [R] programs, the medical risks of NJ Ex Order 26.4(b)(1) [R] involvement, possible 30-day discharge notice from the facility, and revoking of facility out on pass privileges on 5/9/25. All nursing staff were re-educated on signs of overdose and policies to follow in cases of suspected overdose and availability of drug cessation programs for residents on 5/9/25. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Policy signage was posted at the entrance stating that drugs and alcohol are not allowed in the home on 5/9/25. All residents are educated about illicit drug use policy at Resident Council meetings. The Social Worker meets with new residents who have a history of illicit drug use / overdose to discuss policy and options for treatment of addiction. Violations of illicit drug abuse policy are discussed at weekday clinical meetings and reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted, and a QAPI performance improvement project team formed to address clinical concerns. Violations of illicit drug abuse policy are discussed at weekday clinical meetings. Drug overdoses in the home are reported to the Licensed Nursing Home Administrator and Director of Nursing to ensure that the police were called and the New Jersey Department of Health was notified. The Director of Nursing will report on audits of the weekday clinical meetings and any actions taken at the monthly Quality Assurance and Process Improvement Committee meeting for three months. Based on the results of these audits, a decision will be made regarding review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025
Removal Plan
- Provided education to all residents with a history of drug overdose on the medical risks with illegal drug use, police involvement, possible discharge from the facility, and revoking of facility leave privileges.
- Provided education to the residents on cessation programs and psychiatric consultations.
- Placed signage at the entrance of the facility stating that drugs and alcohol were not allowed in the facility.
- Educated facility staff that any drug overdose is to be reported to the appropriate regulatory agencies immediately.
- Educated facility staff on new interventions implemented to help prevent illegal drug use.
- Implemented new interventions including education to the residents on the risks of a drug overdose, room searches, police involvement, possible discharge from the facility, and revoking of facility leave privileges.
- Implemented an audit process during the morning daily clinical meeting to identify residents with a new history of use and any incidents that occur in the facility, ensuring police were called and appropriate regulatory agencies were notified.
- Re-educated administrative staff on their job descriptions and the facility's policies on conducting a thorough investigation and the facility's elimination efforts on illicit drug use at the facility.
- Posted signage in the front of the building that no alcohol or drugs were allowed in the facility.
- Educated all facility staff on elimination of illicit drug use in the facility and to report any illicit drug use to the DOH and the police.
- Audited all incidents and accidents to ensure there were no additional unresolved allegations of abuse, neglect, and illicit drug use identified.
- Implemented an audit process during the morning daily clinical meeting to assess potential abuse and any illicit drug activity and ensure these concerns were addressed per the facility policy.