Failure to Provide Behavioral Health Services and Supervision for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of polysubstance use disorder and recent anoxic brain damage. Upon admission, the resident was noted to be alert but confused, with a documented need for buprenorphine-naloxone (suboxone) to manage opioid withdrawal, as ordered by the hospital physician. Despite these orders, the medication was not available or administered during the resident's stay, and there was no evidence that the physician was notified of the resident's immediate request for the medication. Staff interviews revealed that the resident exhibited signs of withdrawal, anxiety, and agitation, including pacing, crying, and attempting to leave the facility. The resident was placed on one-to-one supervision, but the assigned nursing assistant was unable to maintain continuous supervision when the resident exited the building and ran toward the parking lot. The nursing assistant reported being physically unable to pursue the resident, resulting in the resident leaving the premises unsupervised. Documentation showed a lack of timely intervention and communication regarding the resident's behavioral health needs, including the absence of counseling or education about leaving the facility and failure to ensure the availability of prescribed medication. The facility's policies required staff to provide appropriate behavioral health interventions and maintain close supervision, but these were not effectively implemented for this resident.