Failure to Supervise and Investigate After Resident Drug Overdose and Death
Penalty
Summary
The facility failed to provide adequate supervision and ensure a safe environment for a resident with a known history of substance abuse, resulting in an unexpected death. The resident, who had diagnoses including major depressive disorder, opioid abuse, and cocaine abuse, was found unresponsive in another resident's room after reportedly smoking crack and cocaine with two other residents. An LPN responded to the emergency, administered Narcan twice, and performed CPR, but the resident did not recover. The care plan for this resident included interventions such as random room searches, toxicology screenings, and monitoring for signs of drug use and overdose, but these measures did not prevent the incident. Following the event, interviews revealed that staff were aware of the resident's high-risk status and the facility had policies in place for drug screening and searches, especially for residents returning from authorized out-on-pass visits. Despite these policies, the facility did not conduct or document a thorough investigation immediately after the incident where Narcan was administered. The DON stated that an investigation was not warranted at the time, and key staff involved in the incident were not interviewed promptly. Additionally, the facility's policy required that all incidents and accidents be documented and investigated as soon as they were reported, but this was not followed in this case. The lack of timely and comprehensive investigation, as well as insufficient supervision and monitoring of residents with known substance abuse histories, contributed to the deficient practice identified by the surveyors.