F0656

D

Failure to Implement Person-Centered Care Plan for Resident With Opioid Use Disorder and MAT

Hartford, Connecticut Survey Completed on 01-05-2026

Penalty

Fine: $32,295

Summary

The deficiency involves the facility’s failure to develop and implement a complete, person-centered care plan with measurable interventions for a resident with a known history of psychoactive substance abuse and opioid dependence who was receiving Medication Assisted Treatment (MAT). On admission, assessments documented that the resident was alert and oriented, had used fentanyl within the prior 30 days, and had intact cognition with a BIMS score of 15. The Resident Care Plan identified that the resident was at risk for substance use related to a history of addiction and was receiving MAT, but it did not include specific interventions to address the identified risk for substance use disorder (SUD) or the management of MAT. Physician orders included methadone for opioid use disorder and PRN naloxone for suspected overdose, and the Medication Administration Record showed methadone was administered on multiple days.

Despite the resident’s identified SUD and ongoing MAT, the clinical record did not show that psychiatric/psychology services or contracted SUD program services were offered, provided, or refused. The social worker later stated that the resident had been offered SUD support services through an outside vendor and refused, but there was no documentation of this refusal or of any alternative interventions offered after the refusal. The facility’s Care Plan Policy required that care plans contain identified problems, measurable realistic goals, and interventions to reach those goals, but the Director of Nursing Services acknowledged that the resident’s SUD/MAT plan of care was initiated but not completed and that specific interventions such as supervised visits, random room searches, random urine toxicology screens, and support services were not included. The DNS also reported that room searches were only conducted when there was suspicion or observed contraband, and that the facility had no policy or procedure for suspected drug overdose.

An overdose event occurred when the resident became lethargic, drowsy, and difficult to arouse, with bilateral pinpoint pupils. Nursing staff administered a sternal rub and two doses of naloxone; the first dose was ineffective, and the second dose produced a positive response, after which the resident admitted to using “illegal stuff.” Security and the social worker conducted a room search and found five bags or dime bags with suspicious white residue tucked into the folded rim of the resident’s hat; security reported flushing five empty bags down the toilet. The resident reported bringing the bags into the facility at the time of admission. The resident was transferred to the emergency department for further evaluation, and a toxicology screen was positive for opiates and fentanyl. The DNS confirmed that the resident had no prior room searches before the overdose event, and the police were not notified because the bags were empty. The facility was unable to provide a visitor log for the day of the family visit, and there was no documentation in the clinical record of SUD service refusals or related interventions, contributing to the failure to implement a comprehensive, measurable care plan for the resident’s SUD and MAT.