F0689

K

Failure to Control Opioid-Related Hazards and Provide Adequate Supervision for Residents With SUD

Hartford, Connecticut Survey Completed on 01-05-2026

Penalty

Fine: $32,295

Summary

The deficiency involves the facility’s failure to identify and control accident hazards and to provide adequate supervision and safety interventions for residents with known opioid use disorder, resulting in opioid overdoses for two residents. For one resident with psychoactive substance abuse and opioid dependence with withdrawal, the admission nursing assessment documented fentanyl use within the prior 30 days and intact cognition. The resident’s care plan noted risk for substance use related to a history of addiction and receipt of medication-assisted treatment (MAT), but did not include specific interventions for substance use risk or MAT management. Although physician orders included PRN Naloxone (Narcan) for suspected overdose and daily Methadone for opioid use disorder, the clinical record did not show that psychiatric/psychology services or contracted substance use disorder (SUD) program services were provided or refused.

On one occasion, this resident became lethargic, drowsy, and difficult to arouse, with bilateral pinpoint pupils. A nurse administered two doses of Narcan one minute apart; the first was ineffective and the second produced a positive response, after which the resident admitted to using “illegal stuff.” Security and the APRN were involved, and the APRN documented that the resident admitted to using fentanyl brought into the facility at the time of admission. Security and social work staff conducted a room search and found five bags or dime bags with suspicious white residue tucked into the resident’s hat. Security staff reported that these bags were flushed down the toilet and that no further room searches had been conducted between admission and the overdose event, despite the known SUD history. The DNS acknowledged that the SUD/MAT care plan had been initiated but not completed, that there were no prior room searches, that the police were not notified because the bags were empty, and that the facility had no policy or procedure for suspected drug overdose.

For a second resident with diagnoses including opioid dependence, cocaine dependence, and adjustment disorder, physician orders included PRN Narcan for suspected overdose, Gabapentin three times daily for pain, Sertraline daily for anxiety, and room searches every shift. The resident had intact cognition, was largely independent in mobility and toileting, and had a care plan identifying risk for substance use related to a history of addiction, with an intervention only to observe for signs and symptoms of withdrawal. A nursing note documented that the resident was observed in a wheelchair with slightly slurred speech and dilated pupils but remained alert, oriented, and able to follow commands; the resident refused to provide a toxicology sample and refused hospital transfer, and a room check revealed no contraband. The care plan was later updated to note the episode of dilated pupils and slumped posture, with interventions including 15-minute checks, monitoring labs, evaluating need for psychiatric services, and reinforcing the recovery plan, and documentation showed 15-minute checks were performed for 72 hours.

Subsequently, the DNS documented responding to a STAT call and finding this resident on the bathroom floor with a formed bowel movement, unresponsive to verbal or tactile stimuli and without a pulse. CPR was initiated, 911 was called, and two doses of Narcan were administered without response before transfer to the emergency department, where the resident was pronounced deceased. The hospital record indicated the case was referred to the Medical Examiner due to suspected drug use and noted that facility staff reported the resident had a history of drug use and was observed associating with other residents known to use drugs. The DNS stated she questioned whether to report the unanticipated death to the State Agency and did not contact the Medical Examiner’s office for the cause of death. The Medical Examiner’s report later identified the cause of death as acute intoxication due to the combined effects of fentanyl, gabapentin, and sertraline. The DNS acknowledged that the resident’s care plan for risk of substance use contained only one initial intervention (observation for withdrawal), that additional monitoring beyond the 72-hour 15-minute checks was not implemented, that group therapy attendance was not tracked, and that the facility lacked a policy, procedure, or protocol for suspected drug overdose and Narcan administration.

These failures, including incomplete risk-based care planning for residents with known SUD, lack of specific controls such as supervised visits, random room searches, visitor log management, random urine toxicology, and documented SUD support/refusal handling, absence of an overdose/Narcan protocol, failure to contact law enforcement when illegal drugs were suspected or observed, and failure to maintain chain of custody for contraband, led to one resident requiring two doses of Narcan for a suspected fentanyl overdose and another resident’s death from acute intoxication. Surveyors determined that these failures constituted noncompliance at the level of Immediate Jeopardy.

Removal Plan

• Ensure new admissions with a known recent history of substance use are evaluated for appropriate supervision based on a person-centered risk evaluation, with interventions initiated based on the level of risk.
• Educate nursing supervisors to ensure the Resident Care Plan (RCP) on admission for residents with substance use disorder (SUD) contains interventions to provide adequate support.
• Conduct audits of RCPs for new admissions with a history of SUD to ensure appropriate interventions and adequate supervision.