Failure to Assess Resident After Return Under the Influence
Penalty
Summary
A deficiency occurred when staff failed to assess a resident with a known history of substance abuse after the resident returned to the facility under the influence. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease and substance abuse, had multiple documented incidents involving intoxication and substance use within the facility. Despite staff and resident concerns about the resident's behavior and appearance suggesting intoxication, and the detection of substances in the resident's system, there was no documented nursing assessment completed after the resident returned to the facility on two separate occasions when substance use was suspected. Facility policy required that changes in a resident's condition or status be recorded in the medical record, and the DON stated that an assessment should include vital signs, respiratory effort, pupil checks, and frequent monitoring. However, the clinical record review revealed a lack of such assessments following the incidents, indicating noncompliance with both facility policy and expected nursing practice for residents with known substance use issues.