Failure to Provide Competent Staff and Effective Care Planning for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of a resident with a history of Substance Use Disorder (SUD). Direct care staff reported a lack of training specific to SUD, and the facility's behavioral health training did not include education on SUD. The care plan for the resident lacked a risk assessment for substance use, did not identify triggers or signs and symptoms to monitor for, and did not include interventions for suspected or identified substance use or plans for overdose emergencies. The facility's policy required staff to have education to meet the behavioral health needs of residents, including those with SUD, but this was not implemented in practice. A resident with a history of polysubstance abuse, including methamphetamines, marijuana, and alcohol, as well as diagnoses of Bipolar Disorder, Schizophrenia, and anxiety disorder, exhibited erratic and escalating behaviors during their stay. The resident had multiple incidents of agitation, paranoia, and threats of violence, resulting in hospitalizations and positive drug screens for methamphetamines and opioids. Staff interviews revealed that they had not received training on how to care for residents with SUD and were unsure how to respond to allegations or suspicions of substance use within the facility. Documentation showed that the resident's care plan interventions were limited to monitoring lab results, communicating facility rules, and offering information about substance use programs, but did not address specific strategies for prevention, monitoring, or response to substance use or overdose. Staff reported being told to keep the resident within sight but did not provide one-on-one supervision. The lack of targeted training and comprehensive care planning contributed to the facility's failure to effectively address the behavioral health needs of the resident with SUD.