Failure to Develop Care Plan for Substance Use
Penalty
No penalty information released
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
The facility failed to develop and implement a comprehensive, resident-centered care plan to address the medical and psychosocial needs of a resident with a history of polysubstance use, including alcohol abuse, cocaine use, type II diabetes, and morbid obesity. Despite documentation in the medical record and incident file indicating the resident's ongoing substance use, including an incident where the resident was found smoking an illicit substance in his room, there were no care plans with measurable goals or interventions related to substance use. This omission was confirmed by a social worker who verified the absence of such care planning in the resident's medical record.