Failure to Notify Physician of Resident's Illicit Drug Use and Potential Medication Interactions
Penalty
Summary
The facility failed to notify and consult with a resident's physician regarding the resident's known use of illicit drugs, specifically marijuana, despite the potential for medication contraindications. The resident, who had diagnoses including Parkinson's disease, chronic kidney disease, seizures, and cannabis abuse, was observed multiple times smelling of marijuana and admitted to smoking it outside the facility. Staff interviews revealed that while some staff reported the resident's marijuana use to supervisors or administration, none notified the resident's provider or medical director as required by facility policy. Documentation showed that the resident was prescribed several medications, including gabapentin, lacosamide, levetiracetam, and trazodone, all of which could have potential interactions with marijuana. The care plan identified the resident as a smoker and included interventions for unsafe smoking practices, but did not address the use of illicit substances or the need for provider notification. Staff members expressed uncertainty about their responsibilities, with some believing that once a resident signed out on a leave of absence, they were not responsible for actions taken outside the facility, and others assuming that reporting to a supervisor was sufficient. Both the nurse practitioner and medical director confirmed that they had not been informed of the resident's drug use, and stated that they would expect to be notified of such incidents to prevent possible medication interactions. The facility's policy required prompt notification of the physician and resident representative when there is a change in status or condition, but this was not followed in the case of the resident's ongoing marijuana use.