Failure to Promptly Address Reports of Illicit Drug Use and Ensure a Safe Environment
Penalty
Summary
Facility staff failed to promptly implement interventions after reports of marijuana and a chemical smell were noted in a resident's room. Despite documentation by nursing staff of these odors and a resident being found on the floor with glassy eyes and pinpoint pupils, no immediate action was taken to investigate or address the potential presence of illicit substances. The clinical records for both residents involved did not mention any interventions or follow-up regarding the reported smells until two days later. One resident, with a history of traumatic brain injury, epilepsy, and substance abuse, was found on the floor and later experienced seizure-like activity. During an emergency room visit, this resident tested positive for marijuana and methamphetamine. The roommate, who also had a history of substance abuse, was found in possession of multiple prohibited items, including vape devices, glass smoking devices, and empty THC containers, but this was only discovered after a delayed search of the room. Prior to this, there was no documentation of any investigation or search in response to the initial report of suspicious odors. The facility's inaction following the initial report of marijuana and chemical smells resulted in a lack of timely assessment and intervention to ensure a safe, drug-free environment. There was no documented investigation into how the resident tested positive for illicit drugs, and care plans for both residents did not reflect the risks or history of substance abuse at the time of the incident. The failure to act promptly on staff observations and to update care plans contributed to the deficiency in maintaining a safe environment free from accident hazards and illicit substances.