Failure to Implement and Monitor Alcohol Reduction Plan for Resident
Penalty
Summary
The facility failed to implement, monitor, and modify interventions to reduce the risk of avoidable accidents related to alcohol consumption for a resident with alcohol dependence and other significant health conditions. Despite a physician's order for a gradual reduction in alcohol intake and a plan involving staff supervision and documentation, there was no evidence that these interventions were put into practice or documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for several months. The resident was allowed to store alcohol in their room and personal vehicle, and staff did not consistently track or supervise the amount of alcohol consumed as required by facility policy and physician orders. Interviews with staff revealed that documentation of alcohol dispensation was inconsistent and that staff were not reviewing the total daily intake. The resident did not use the facility sign-out sheet when leaving the premises, and staff were only aware of their absences through verbal reports. The Director of Nursing confirmed that the required monitoring and documentation should have been implemented earlier, and the Administrator was unaware that the reduction plan was not being followed. These lapses in supervision and documentation placed the resident at risk for negative outcomes related to excessive alcohol consumption.