Failure to Report Suspected Abuse or Neglect After Unexplained Fentanyl Exposure
Penalty
Summary
The facility failed to report an alleged violation that could constitute abuse or neglect to the State Survey Agency after a resident was found unresponsive and later tested positive for fentanyl, despite having no physician orders for opioid medications. The resident, a male with multiple diagnoses including dementia, atrial fibrillation, and hemiplegia, was dependent for all care and non-ambulatory, but had intact cognitive skills. On the day of the incident, he was found unresponsive in his wheelchair in a common area, exhibiting shallow breathing, and was subsequently transferred to the hospital where EMS administered Narcan and a toxicology screen revealed fentanyl in his system. Review of the resident's medication administration record confirmed there were no prescribed opioids or fentanyl patches for him. Interviews with staff indicated that the resident had not been given any opioids and had no access to narcotics. The resident's representative also confirmed that he had never taken opioids and had no known access to them. Despite these findings and the involvement of local law enforcement, the facility did not report the incident as a potential case of abuse or neglect to the State Survey Agency. The Executive Director and Assistant Executive Director acknowledged awareness of the incident and the police investigation but did not initiate a report to the appropriate authorities, citing uncertainty about the source of the fentanyl. The internal investigation conducted by the facility was limited, and there was no documentation of staff interviews by the facility itself, as the police had conducted interviews. The decision not to report was based on the facility's inability to determine how the fentanyl exposure occurred.