Failure to Assess and Care Plan for Substance Abuse History
Penalty
Summary
The facility failed to assess and document a resident's history of substance abuse upon admission, despite clear indications in the medical record and hospital transfer documents. The resident, who had a documented history of methamphetamine, crack/cocaine, and marijuana use, was admitted for generalized weakness and had recently transferred from another facility and a hospital stay. The physician's History and Physical (H&P) and social services assessment both noted the resident's substance use history, but this information was not entered into the electronic health record under diagnoses, nor was it addressed in the nursing assessment or Minimum Data Set (MDS) documentation. No nursing care plan was initiated to address the resident's substance abuse history, and the issue was not incorporated into the resident's plan of care upon admission. Staff interviews confirmed that the resident exhibited non-compliance with medication, safety routines, and smoking policies, and that his wife brought potentially hazardous items into the facility. The resident was also described as verbally aggressive and uncooperative regarding discussions about substance use. Despite these behaviors and the known history of substance abuse, the facility did not implement targeted interventions or a care plan to address these risks. The deficiency became evident when the resident experienced a sudden change in mental status and vital signs, leading to a hospital emergency room admission where a drug screen was positive for methamphetamine. The lack of a comprehensive care plan and failure to document and address the resident's substance abuse history may have contributed to the health incident and the presence of accident hazards in the facility.