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F0550
D

Failure to Follow Physician Orders and Community Pass Policy

Indian Head Park, Illinois Survey Completed on 09-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of alcohol abuse, anxiety disorder, major depressive disorder, PTSD, suicidal ideations, anemia, insomnia, psychoactive substance abuse, and schizophrenia was found to be cognitively intact and had an active physician order for independent community pass. Despite this, the facility restricted the resident's community pass for 30 days after another resident alleged that the individual had brought a marijuana pen into the facility. Staff searched the resident's room and found no contraband, and there was no documentation of symptoms indicating the resident was under the influence of any illicit substance. The resident refused to provide a urine sample and became agitated, but there was no evidence of intoxication or possession of drugs. The facility's community pass policy states that pass privileges may be revoked if a resident returns intoxicated or under the influence, and drug testing may be conducted if there is suspicion after an overnight pass. In this case, the resident had not been out overnight, and there was no credible evidence to support the restriction of the community pass. The decision to restrict the pass was based solely on an unsubstantiated allegation and the resident's refusal to provide a urine sample, without any documented clinical indications or policy-based justification.

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