Failure to Monitor and Address Substance Abuse and Self-Harm Risks
Penalty
Summary
The facility failed to follow its own policies and procedures for behavior and substance abuse management, resulting in inadequate monitoring and communication regarding suspected or observed substance use among residents. Specifically, staff did not conduct room searches as required when there was suspicion of substance abuse, did not refer suspected substance abuse cases to law enforcement, and failed to document or implement personalized care plan interventions for the prevention of suicidal or self-harming behavior and substance use. These failures were observed in two residents who subsequently tested positive for drug use while in the facility, with one resident engaging in self-harming behavior. One resident with a history of severe mental illness, substance abuse, and self-harm was admitted following psychiatric hospitalization for suicidal ideation and self-injurious behavior. Despite documented risks and a care plan indicating the need for monitoring, the resident's care plan did not include specific interventions for substance abuse or self-harm. The resident was found participating in rule-violating group activities, eloped from the facility, and later tested positive for cannabinoids and cocaine after reporting ongoing drug use and self-harm within the facility. There was no documentation of room searches, physician notification, or counseling regarding substance use during the resident's stay. Another resident with a history of polysubstance use disorder and psychiatric diagnoses also lacked a care plan with personalized interventions for substance abuse triggers or diversions. This resident was found with contraband, suspected of drug use, and later tested positive for cocaine after being sent to the hospital for psychiatric evaluation. Staff and other residents reported frequent observations of drug use, odors, and paraphernalia in the facility, but there was a lack of consistent documentation, communication, and follow-through on required interventions such as room searches, physician notification, and law enforcement referral. The facility's policies required these actions, but they were not implemented or documented as required.