Failure to Develop and Implement Substance Abuse Care Plan and Notify Physician
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional nursing standards for a resident with a known history of THC (tetrahydrocannabinol) substance abuse. The resident was admitted with multiple diagnoses, including a right knee fracture, major depressive disorder, anxiety, and difficulty walking. Documentation showed that the resident had a social history of THC use, and on two separate occasions, THC products were found in the resident's room. Despite these findings, there was no evidence that a care plan addressing substance use was developed, nor was there documentation of physician notification regarding the resident's substance abuse. Interviews with facility staff, including licensed nurses, a CNA, the Social Service Director, and the Social Services Assistant, confirmed that no substance abuse care plan was created and the physician was not notified after THC was found. Staff members stated that they would have expected a care plan to be implemented and the physician to be notified to ensure the resident's safety and appropriate care. The resident herself confirmed that she was not provided with an individualized substance abuse care plan upon admission or after the discovery of THC in her room, and expressed that such a plan would have been helpful. A review of facility policies indicated that comprehensive care planning and physician notification are required following resident assessments and any change in condition, including incidents involving substance abuse. The facility's failure to follow these policies resulted in the lack of monitoring, care planning, and physician involvement for the resident's substance abuse, as documented in the resident's records and confirmed by staff interviews.