Failure to Develop Comprehensive Care Plan for Resident with Substance Abuse History
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a documented history of substance abuse. The resident had multiple diagnoses, including hypertension, cerebral infarction, arthritis, history of falls, diabetes, schizophrenia, and substance abuse. Despite previous incidents where the resident admitted to smoking drugs in her room and was found in possession of drug paraphernalia, the care plan only included basic interventions such as installing a smoke detector, temporarily restricting leave of absence visits, and supervised visitation. Subsequent events included the discovery of a crack pipe and suspected crack cocaine in the resident's possession, as reported by the nursing supervisor and confirmed by the NHA. The physician's notes also documented concerns about ongoing cocaine use and recommended close monitoring for signs and symptoms of drug abuse. Review of the resident's clinical record and care plan revealed that there was no detailed or updated plan addressing the prevention of drug and paraphernalia possession, nor were there specific interventions for supervision tailored to the resident's substance abuse history. Interviews with facility leadership confirmed that the care plan lacked detailed strategies for supervision and prevention of drug access, despite repeated incidents and physician recommendations for close monitoring. The deficiency was cited under relevant state codes for failure to provide adequate resident care planning and nursing services.