Failure to Prevent Accident Hazard Due to Unsecured Alcohol
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate interventions to prevent potential accidents for a resident with a history of substance use and multiple medical conditions. The resident, who was moderately cognitively impaired and used a manual wheelchair, had an invoked Power of Attorney (POA) for healthcare decisions. The resident's care plan and provider orders allowed for alcohol consumption only on holidays or special events, yet the resident was found to have an unsecured bottle of alcohol in their room for an extended period, accessible at any time. Staff interviews and record reviews revealed that several staff members, including nursing assistants and social services, were aware of the bottle of alcohol in the resident's room but did not take action to secure or remove it, believing the resident had an order for alcohol. However, the order was limited to specific occasions, not for unsupervised possession. There was no documentation of a self-administration assessment to determine if the resident could safely manage alcohol, nor was there evidence of provider or POA notification regarding the unsecured alcohol. Additionally, after the resident was found intoxicated, there was no record of an alcohol toxicology test being completed as part of the emergency room visit, despite a provider order for a toxicology screen. The resident's POA was not informed about the presence of alcohol in the room until after the intoxication incident. The facility's social services staff had previously consulted with the Ombudsman regarding confiscation of alcohol, who advised that alcohol could not be taken from a resident without their consent. Despite this, the facility did not ensure that the resident's access to alcohol was consistent with the provider's order or that appropriate safety measures were in place, resulting in a failure to prevent a potential accident hazard.