Failure to Control Visitor-Introduced Substances and Supervise High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistance to a resident with a known history of substance abuse and prior fentanyl overdose. The resident was admitted with psychoactive substance abuse and paraplegia, required assistance with ADLs and transfers, and had care plans and policies in place related to substance use disorder, smoking, visitation, and comprehensive care planning. Despite these, the facility did not consistently assess, monitor, or document signs and symptoms of substance use or abuse as required by the resident’s care plans and the facility’s policies. Staff documented that a family member frequently stayed overnight in the resident’s room and engaged in unspecified suspicious behavior that led to police notification, but there was no documented investigation, IDT follow‑up, or reassessment of the resident for substance use or abuse after this event. The facility also failed to adequately address multiple specific incidents involving contraband substances and unsafe smoking. On one occasion, an LVN observed the resident vaping a substance that smelled like marijuana in his room, with his roommate coughing from the smoke. The resident was later found in possession of vape pens, a marijuana “live resin” vape, and non‑prescribed Blue Chew erectile enhancement pills, which were confiscated. Progress notes and interviews show that although these items were removed and a care plan was created to monitor for changes related to non‑prescribed medications, there was no documented ongoing monitoring for substance use, suspicious behaviors, or adverse effects, and the physician was not informed of these incidents. Staff also documented complaints of the resident’s room smelling like marijuana when the resident was with a visitor, but there is no evidence that the substance abuse care plans were revised with new interventions in response. The facility further failed to enforce its smoking and visitation policies and to implement increased supervision despite repeated incidents involving the same visitor. A smoking evaluation documented that the resident was not allowed to smoke due to being under the legal smoking age and unable to safely hold a cigarette, yet a restorative nursing attendant later observed the same family member placing an unknown smoking material in the resident’s mouth outside the front of the facility. Staff and the administrator approached and educated the resident, and an NP ordered close monitoring for changes in level of consciousness, but there is no documentation of reassessment for substance use or abuse or of specific supervision of visits. Subsequently, the same family member visited again; staff entered the resident’s room, noted smells of smoke, marijuana, and alcohol, and found the resident vomiting, foaming at the mouth, and unable to hold his head up. The visitor admitted providing alcohol, and hospital records confirmed acute alcohol intoxication. After the resident’s return, visitor logs show that the same family member continued to visit without documented restrictions or supervised access, and interviews confirm that staff were not instructed to monitor or supervise visits or to watch for specific substance‑related behaviors, despite the resident’s history and prior documented incidents.
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