Failure to Monitor and Investigate Resident Illicit Drug Use
Penalty
Summary
The facility failed to implement an effective system to monitor and investigate how a resident with a known history of substance abuse was able to obtain and use illicit drugs while residing in the facility. Despite the resident being cognitively intact and having no independent outside pass privileges, there were multiple documented incidents where the resident was found in possession of illicit substances and drug paraphernalia, and subsequently tested positive for cocaine, fentanyl, and opiates. Staff discovered a white powdered substance and a crack pipe in the resident's room on more than one occasion, and hospital records confirmed the resident's admission of drug use within the facility. There was a lack of consistent documentation and follow-through regarding the monitoring and supervision of the resident after each incident. Although the resident's care plan and behavior contract addressed substance abuse, there were no additional interventions documented after repeated hospitalizations for drug use. The facility's own policies required immediate assessment, drug screening, and restriction of passes, but there was no evidence of a thorough investigation into how the drugs were obtained or brought into the facility. Staff interviews revealed uncertainty about the process for handling contraband, inconsistent communication, and a lack of clarity regarding the involvement of law enforcement or addiction specialists. Furthermore, there was insufficient documentation of frequent monitoring and supervision of the resident following each incident, as required by facility policy. Staff did not consistently document monitoring on various shifts, and there was no evidence of a substance abuse assessment, psychiatric evaluation, or referral for addiction treatment after the resident's repeated positive drug screens and hospitalizations. The facility's failure to investigate the source of the drugs and to implement effective interventions contributed to the ongoing risk and ultimately resulted in the resident requiring multiple hospital transfers due to drug use while in the facility.