Failure to Monitor and Investigate Illicit Drug Use Resulting in Resident Overdose
Penalty
Summary
The facility failed to have a system in place for monitoring and investigating how illicit drugs entered the facility, to be alerted when illicit drugs were present, and to prevent resident use and possible drug overdose. This deficiency was identified after a resident with a known history of substance abuse obtained and used illicit drugs while in the facility, resulting in a drug overdose that required the administration of Narcan and emergent hospital transfer. Interviews and record reviews revealed that the facility did not conduct an investigation into how the drugs were brought in or how the resident accessed them, nor did they follow up with involved residents or staff regarding the incident. The resident involved had a documented history of substance abuse, including cocaine, marijuana, and alcohol, and had previously been admitted to behavioral health and substance abuse treatment centers. On the day of the incident, the resident was found unresponsive in another resident's room, and staff administered Narcan after observing symptoms consistent with opioid overdose. The resident later admitted to using heroin with another resident. Despite this, there was no documentation of an investigation into the overdose, and key staff members, including the DON and administrator, did not follow up with staff or residents to determine the source of the drugs or to assess the situation further. Other residents and staff reported knowledge or suspicion of drug use and distribution within the facility, including observations of abnormal behaviors and direct admissions of drug use. The facility's policies required reporting, recording, and investigating all accidents and unusual occurrences, including those requiring emergency services or resulting in hospitalization. However, these procedures were not followed in this case, as there was no accident report or investigation into the overdose incident, and the facility did not notify the appropriate parties or take steps to identify and address the source of the illicit drugs.