Failure to Individualize Care Plans for Residents with Substance Use Disorder
Penalty
Summary
The facility failed to develop and implement individualized care plans for residents with substance use disorder (SUD), as evidenced by medical record reviews of three residents. One resident with intact cognition and a diagnosis of SUD was found unresponsive and required emergency interventions including CPR, multiple doses of Narcan, and use of an AED. The care plan for this resident only included general monitoring and medication administration, omitting specific interventions such as participation in SUD group meetings, 1:1 support, and mental health or recovery services, despite the resident's involvement in these activities. There were also no documented notes from the social worker or evidence of interdisciplinary discussion regarding interventions in the quality assurance records. Another resident with SUD was found unresponsive in the courtyard and required Narcan administration before regaining consciousness. The care plan for this resident lacked documentation of SUD-specific interventions, such as group meetings or mental health services, even though the resident was receiving these services. A third resident with a history of opioid use and recent Narcan administration did not have an updated care plan reflecting behavioral health involvement, behavioral contracts, or references to SUD nurse practitioner visits or group participation. In all cases, interviews with facility leadership yielded no responses regarding the deficiencies in care planning.