Failure to Prevent Unauthorized Alcohol Consumption
Penalty
Summary
The facility failed to provide adequate supervision to prevent residents from obtaining and consuming alcohol on the premises. Five residents, all with varying medical diagnoses such as cerebral palsy, morbid obesity, heart disease, COPD, and mental health disorders, were found drinking alcohol together in a dining room. These residents had BIMS scores indicating intact or mildly impaired cognition. Staff, including a nurse and a CNA, observed the group drinking from plastic cups and detected the smell of alcohol. The incident was confirmed through camera footage, and one resident later admitted to drinking alcohol in a written statement. The facility's policy requires a physician order for alcohol consumption, but no such orders were present for any of the involved residents. The event was reported by staff who witnessed the group in the act and attempted to intervene, but the residents refused to allow a search of their belongings. The nurse notified the physician and the resident's power of attorney, and a urine test was ordered for one of the residents. Despite the facility's policy and the presence of supervision, the residents were able to access and consume alcohol without authorization, and the source of the alcohol could not be determined. The lack of effective supervision and failure to enforce policy led to an unsafe environment for the residents involved.