Failure to Address Illegal Substance Use in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement care plans addressing the use of illegal substances for two residents with histories of substance use and mental health diagnoses. One resident with schizoaffective disorder, opioid dependence, and psychotic disorder was found smoking an illegal substance using a soda can, as documented in a nurse note, but their care plan did not address this behavior. Another resident with major depressive disorder, hypoxemia, and alcoholic hepatitis was also found smoking an illegal substance from a soda can, with no corresponding care plan intervention. Both residents had been caught multiple times engaging in this behavior, and staff interviews confirmed that care plans were not developed to address the issue.