Failure to Revise Care Plan After Resident Drug Abuse Incident
Penalty
Summary
The facility failed to revise the care plan for a resident with a known history of drug abuse after an incident in which the resident was found unresponsive and tested positive for fentanyl, a medication not prescribed to them. The resident had multiple medical diagnoses, including hemiplegia, hepatic encephalopathy, dysphagia, aphasia, and vascular dementia, and was assessed as having moderate cognitive impairment and short-term memory problems. Despite documentation in the resident's medical records and emergency room notes indicating a history of drug abuse and a previous overdose, the care plan was not updated to reflect these significant risk factors or the recent incident involving fentanyl. Interviews with facility staff, including the MDS Coordinator, ADON, and DON, confirmed that the resident's care plan was not revised to address the history of drug abuse or the fentanyl incident. The facility's own policy required the interdisciplinary team to review and revise care plans after each assessment and when a resident's clinical status or condition changes. However, the care plan review conducted after the incident did not include any updates related to the resident's substance abuse history or the unresponsive episode, despite clear evidence and staff acknowledgment that these issues should have been addressed.