Failure to Intervene for Substance Use and Address Hospital Wound Care Instructions
Penalty
Summary
The facility failed to provide appropriate interventions and care for two residents with significant medical needs. In the first case, a resident with a known history of substance use disorder was admitted following hospitalization for septic wounds and endocarditis related to suspected drug use. The resident had a central catheter and was prescribed Suboxone for opioid withdrawal, but repeatedly refused the medication. Staff documented that the resident appeared to be under the influence and was unavailable for medications and wound care on multiple occasions. Despite these observations and the resident later being found unresponsive and requiring Narcan administration, there was no evidence that mental health services were notified or that a multidisciplinary meeting occurred to address the relapse concerns. The physician was also not informed of the repeated Suboxone refusals. In the second case, another resident was admitted with multiple traumatic injuries and surgical wounds following a motor vehicle accident. The hospital discharge summary included specific instructions for wound care and follow-up appointments. However, the facility's admission assessment did not identify the presence or location of the surgical wounds, and there were no physician orders or documentation on the Treatment Administration Record (TAR) for wound care as outlined in the hospital instructions. The care plan addressed only the prevention of pressure ulcers and did not include the resident's surgical wounds or their care. The Director of Nursing confirmed that wound care orders should have been present upon admission, but no additional documentation was found. These deficiencies were identified through interviews, medical record reviews, and discussions with facility leadership, demonstrating failures to intervene appropriately for substance use concerns and to ensure continuity of care for surgical wounds as directed by hospital discharge instructions.