Failure to Prevent and Control Illicit Drug Use and Distribution
Penalty
Summary
The facility failed to maintain an effective contraband policy to prevent illicit drugs from being brought into, distributed, and used within the facility. Multiple residents were found to have tested positive for fentanyl and opiates, with two residents experiencing significant medical emergencies as a result. One resident was observed slumping forward in a wheelchair, became cyanotic, and required Narcan administration after testing positive for opiates and fentanyl. Another resident was transported to the hospital for a change in condition and also tested positive for fentanyl and opiates metabolites. Both residents had a history of substance abuse and were cognitively intact at the time of the incidents. Interviews and record reviews revealed that the facility did not have a plan to determine how illicit drugs were entering the premises. There were reports and witness statements indicating that drugs were being brought in and distributed by both residents and possibly staff, including allegations of a female night staff member supplying drugs. The facility's investigation into staff involvement was inconclusive, and there was a lack of documentation regarding interviews and searches. Additionally, the facility's contraband policy was not effectively enforced, as evidenced by the discovery of drug paraphernalia in resident rooms and ceilings, and by multiple residents admitting to purchasing and using illicit substances within the facility. Staff interviews indicated gaps in communication and awareness regarding residents' substance use and related hospitalizations. There was also a lack of clarity among staff about when to administer Narcan, and the facility failed to present a policy or practice related to its use. The facility's response to suspicious behavior, drug screening, and supervision was inconsistent, and documentation of investigations and interventions was incomplete. These failures affected not only the residents who experienced overdoses but also had the potential to impact all residents reviewed for illicit substance or contraband issues.