Failure to Monitor and Supervise Resident with History of Drug Distribution Leads to Multiple Overdoses
Penalty
Summary
The facility failed to provide ongoing monitoring and close supervision of a resident with a known history of non-compliance with facility rules, specifically related to obtaining and distributing unauthorized and/or illegal drugs. Despite previous incidents and documented behaviors, the resident was not consistently placed on one-on-one monitoring or subjected to drug screening as required by facility policy when there was suspicion of drug use. On multiple occasions, this resident was able to bring illegal substances into the facility and distribute them to other residents, resulting in several overdoses. On one occasion, three residents required cardiopulmonary resuscitation (CPR) and were hospitalized after overdosing on unauthorized substances, with drug screens confirming the presence of illegal drugs. The facility's own investigation and video footage confirmed that the resident in question received money from other residents and was involved in the distribution of drugs. Despite these findings and the resident's return to the facility, staff failed to implement required monitoring and did not obtain a drug screen when the resident exhibited suspicious behaviors, such as being slow to respond and inappropriate laughter. As a result of these lapses, additional residents experienced overdoses, with one resident suffering cardiac arrest and being admitted to hospice care due to anoxic encephalopathy. Other residents also tested positive for illegal substances and reported purchasing drugs from the same resident. The facility's failure to follow its own policies for monitoring, drug screening, and supervision directly contributed to repeated incidents of drug use and distribution among residents, resulting in significant harm.