Failure to Assess and Intervene for Substance Abuse and Fall Risk
Penalty
Summary
The facility failed to comprehensively assess and implement interventions to reduce the risk of accidents or injury for residents with a history of substance abuse and for a resident at high risk for falls. For two residents with substance abuse histories and suspected current use, there was a lack of documented interventions, assessments, or monitoring protocols in their electronic medical records. Staff reported concerns and observed signs of possible substance use, such as glassy eyes, slurred speech, and the smell of burning, but these concerns were not addressed through care planning or monitoring. The facility's own policy required assessment and individualized care planning for substance abuse, but this was not followed, and staff interviews confirmed the absence of such measures. One resident with a history of substance use was observed by staff to display symptoms consistent with intoxication, and staff reported these concerns to management multiple times without any documented follow-up or intervention. Another resident admitted to past drug use and was reported by a peer to be using illicit substances in the facility, including barricading the door and threatening others. Despite these reports and a care plan noting substance use disorder, the only intervention offered was chemical use counseling, which the resident declined. There was no evidence of ongoing monitoring or comprehensive assessment as required by facility policy. For a resident at high risk for falls, the facility did not implement new interventions following a recent fall. The care plan listed previous interventions, but after the most recent incident, there was no evidence of therapy involvement or updated interventions. Staff interviews revealed that therapy orders were not obtained, and the director of rehabilitation confirmed that no new therapy had been initiated. The facility's protocols required immediate intervention and care plan updates after a fall, but these actions were not taken, leaving the resident without additional support to prevent further incidents.