Failure to Develop Care Plan for Illicit Substance Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing illicit substance use for a resident after drug paraphernalia was discovered in the resident's room. Documentation showed that a housekeeper found a tissue box containing a broken glass pipe with a white substance, foil, scissors, and a burned light bulb. The incident was reported to administration, and the paraphernalia was collected, but no incident report was completed, and law enforcement was not contacted. The resident involved had moderately impaired cognition, a BIMS score of 09, was independent with activities of daily living, and had a diagnosis of cirrhosis of the liver. Despite the discovery of items suggestive of illicit drug use, the resident's care plan did not include any goals or interventions related to substance abuse. Staff interviews confirmed that the care plan should have addressed substance use following the incident, but no such updates were made. The facility's policy required care plans to identify problem areas and develop targeted interventions, which was not followed in this case.