Failure to Develop and Implement Care Plan for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a known history of stimulant abuse, despite the resident's recent positive urine drug screening for methamphetamine and fentanyl. Upon admission, the resident was diagnosed with a deep skin infection and stimulant abuse, and was found to be cognitively intact and capable of making decisions. Multiple nursing notes documented the resident spending unsupervised time outside with a significant other, and subsequent hospital records confirmed intoxication and positive toxicology results for methamphetamine and fentanyl. After returning from the hospital, there was no documentation of a care plan addressing the resident's substance use, nor evidence of staff monitoring or intervention related to the ongoing risk. Interviews with facility staff, including a licensed nurse, physical therapist, activities director, social service director, and the DON, revealed that the resident and her significant other were frequently unsupervised outside, and that staff were aware of the resident's substance use history and recent positive drug screening. Staff confirmed that no care plan had been developed or implemented to address the resident's substance use, and that there was no communication or coordinated approach among the interdisciplinary team regarding the situation. The resident herself confirmed recent drug use on facility premises, specifically in unsupervised outdoor areas. A review of the facility's policy and procedure for care of residents with substance use disorder indicated that an individualized care plan should be developed for residents with a history of substance abuse, including monitoring and risk management interventions. Despite this policy, the facility did not initiate a care plan or implement monitoring for the resident, resulting in a lack of coordinated care and oversight for a resident at risk for ongoing substance use and related complications.