Failure to Assess and Address Substance Abuse Disorder in Resident
Penalty
Summary
The facility failed to ensure that a resident with a known substance abuse disorder received appropriate behavioral health care and services. The resident, who had a diagnosis of alcohol dependence with withdrawal and a legal guardian for medical decisions, was able to leave the facility on a leave of absence without proper oversight. The resident was missing for approximately 1.5 days and was later found at a hospital, where he was treated for alcoholic ketosis, withdrawal, dehydration, and lactic acidosis after consuming alcohol during his absence. Review of the resident's clinical records and hospital documentation confirmed recent alcohol consumption, despite previous psychiatric notes stating the resident did not currently drink alcohol. The hospital records detailed the resident's symptoms, including chest pain, generalized pain, vomiting, and heat exposure, and confirmed treatment for alcohol withdrawal and related complications. The resident's care plan and social services progress notes did not address his substance use disorder, and there was no documentation of interventions or discussions regarding his alcohol abuse. Interviews with facility staff, including the social worker and administrator, confirmed that no care plan or interventions were in place to address the resident's alcohol abuse disorder. Additionally, the facility was unable to provide a policy regarding the management of residents with substance abuse disorders when requested by surveyors. These findings indicate a lack of assessment and intervention for the resident's behavioral health needs related to substance abuse.