Failure to Monitor and Assess Residents Following Illicit Drug Use Incident
Penalty
Summary
The facility failed to properly monitor and assess two residents in relation to illicit drug use and exposure. One resident with a history of bipolar disorder, cocaine use, and alcohol abuse was observed by staff actively smoking an illicit substance in his bathroom. Staff, including a CNA and two LPNs, witnessed the resident using drug paraphernalia and attempting to conceal the substance. Despite the incident, there was no documentation of restrictions or interventions implemented to prevent further drug use or to monitor the resident for subsequent behaviors. The resident refused to sign a behavior contract and was discharged shortly after the incident. The resident's roommate, who had multiple chronic conditions including COPD, dementia, and chronic respiratory failure, was in close proximity to the incident. Despite the exposure to smoke from the illicit substance, there was no immediate assessment or documentation of the roommate's condition following the event. The initial assessment of the exposed resident was not completed until the following day, and it revealed a notably low blood pressure reading. There was no documentation that the physician or nurse practitioner was notified of this abnormal finding, and the staff could not confirm if any notification occurred. Interviews with facility staff, including the DON, LPNs, and the CNP, confirmed that no timely assessment or monitoring was conducted for the exposed resident. The CNP and physician both stated that an immediate assessment and ongoing monitoring would have been expected following such exposure, especially given the resident's respiratory conditions. The lack of prompt assessment and failure to notify medical providers of abnormal vital signs contributed to the deficiency identified during the survey.