Failure to Provide Behavioral Health Services and Monitor Substance Use
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a documented history of substance use and multiple behavioral health diagnoses, including adverse effects of methamphetamines, cannabis abuse, suicidal ideations, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder. The resident's comprehensive care plan did not address their history of substance use/abuse, despite this being known at admission and confirmed by both the administrator and MDS coordinator. Additionally, the resident's Minimum Data Set (MDS) assessments did not indicate substance use/abuse or PTSD, contrary to the resident's medical history. Provider progress notes documented ongoing concerns, including drug diversion, active substance abuse within the facility, and the resident taking medications not prescribed to them. These concerns were not addressed by facility staff, and the administrator was unaware of these issues at the time of the resident's death. Furthermore, although there was a physician's order for monthly urine drug screens (UDS), these were not performed as ordered after the initial positive result for methamphetamine. Staff interviews confirmed that the required monthly UDS were not completed.