Failure to Monitor and Supervise Resident with Substance Abuse History and Oxygen Use
Penalty
Summary
The facility failed to identify and implement appropriate monitoring and supervision for a resident with a known history of methamphetamine use, despite multiple documented instances of positive toxicology screens for amphetamines. After a hospital toxicology report indicated a positive result for amphetamines, the facility's interdisciplinary team only provided education to the resident about the risks of recreational drug use and did not establish a care plan or interventions to monitor for ongoing substance abuse. There was no evidence that staff were informed of the resident's drug history, nor were there protocols in place to monitor for signs of substance use or to update the resident's care plan accordingly. Additionally, the facility did not secure or prevent the resident from possessing smoking items, such as cigarettes, a glass pipe, and lighters, even though the resident was assessed as a non-smoker and had active orders for continuous oxygen therapy. Staff discovered lighters in the resident's room on multiple occasions, but there was no documentation of a personal belongings inventory update or consistent monitoring of the resident's possessions. The facility's policies required confiscation and documentation of hazardous items, but these procedures were not followed, and staff were unaware of the presence of these items until after a critical incident occurred. The lack of monitoring and supervision resulted in the resident experiencing a medical emergency characterized by tachycardia, oxygen desaturation, and shortness of breath, necessitating emergency transport to a hospital where the resident tested positive for amphetamines and methamphetamines and required intubation. Subsequent investigation revealed the presence of narcotics and a meth pipe in the resident's room, as well as multiple lighters, despite facility policies prohibiting such items for residents on oxygen. Staff interviews confirmed that there was no training on recognizing signs of methamphetamine use, no communication about the resident's drug history, and no updated inventory of the resident's belongings.