Failure to Implement Comprehensive Care Plan for Resident with Substance Use Disorders
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with known alcohol dependence, alcohol abuse, and opioid dependence. Upon admission, the resident's diagnoses and history indicated a high risk for substance use and withdrawal, with recommendations for supportive group referrals and possible medication interventions. Despite these identified needs, the facility did not ensure the resident was connected to community support groups, did not develop or sign a behavior contract, and did not provide or assist in obtaining substance use treatment services such as behavioral health support, medication-assisted treatment, or access to support meetings. Documentation revealed that although the care plan included interventions such as monitoring for cravings, room searches for paraphernalia, and working with the resident to identify coping mechanisms, there was no evidence these interventions were actually implemented. The facility also failed to obtain or document physician orders for a monthly injection to reduce substance abuse cravings, despite repeated mentions by the resident's responsible person and care team. Additionally, there was no documentation that the facility staff were trained on recognizing or responding to signs and symptoms of substance abuse, withdrawal, or overdose prior to a critical incident. The lack of implementation and follow-through on the care plan resulted in the resident experiencing a heroin overdose, requiring emergency intervention with Narcan administered by paramedics. The facility did not have an order for the opioid reversal agent, nor did staff administer it as outlined in the care plan. After the overdose, the care plan was not reassessed or updated, and there was no evidence of further action to address the resident's ongoing needs related to substance abuse and dependence.