Failure to Provide Behavioral Health Services and Substance Abuse Interventions
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents with histories of substance abuse, in violation of its own Behavior Management and Resident Drug and Alcohol Abuse policies. Both residents were admitted with known substance abuse issues and continued to use and abuse illegal substances while on leave of absence (LOA) from the facility. Despite multiple documented overdoses occurring within the facility, including several instances where staff had to administer Narcan to revive one resident, the facility allowed both residents to continue taking LOAs and return to the facility while intoxicated. There was a lack of consistent documentation and follow-up regarding the residents' substance use, and the care plans and behavior contracts did not adequately address or adapt to the ongoing non-adherence and repeated incidents. One resident had a documented history of opioid, cannabis, and alcohol abuse, and was admitted for rehabilitation. This resident experienced multiple overdoses within the facility, requiring emergency interventions and hospitalizations. The facility's records show repeated LOAs, sometimes for days, with the resident returning in an impaired state. Despite these events, the care plan interventions were limited to encouraging counseling and re-education on the facility's drug policy, with no evidence of effective interdisciplinary team (IDT) collaboration or revision of the care plan in response to ongoing substance use. The facility also failed to consistently document drug screenings and did not provide timely or effective referrals to local substance abuse resources. The second resident, also with a history of psychoactive substance abuse, was admitted with an ankle monitor and had multiple hospitalizations for overdose and severe intoxication. This resident made threats of violence and exhibited inappropriate behaviors toward staff, yet was still permitted to leave the facility and return while intoxicated. The facility's response did not include effective behavioral health interventions or consistent monitoring, and there was insufficient documentation of IDT involvement or adaptation of the care plan to address the resident's ongoing substance abuse and behavioral issues. Staff interviews revealed a lack of clear direction and training on managing residents with substance abuse problems, and the facility did not follow its own policies regarding assessment, intervention, and provision of local resources for substance abuse treatment.