Failure to Develop and Implement SUD Care Plans for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement individualized care plans for residents with diagnosed substance use disorder (SUD). Record review showed that three sampled residents, each with SUD documented on their admission records, did not have SUD care plans in place prior to a specified date. For each of these residents, the DON confirmed during concurrent interviews and record reviews that no SUD care plan had been developed, despite the presence of SUD as an active diagnosis. The DON stated that SUD care plans were important to monitor for potential withdrawal symptoms and drug-seeking behavior, and acknowledged that the absence of such care plans meant the residents’ psychosocial well-being was not being monitored in relation to their SUD. During a phone interview and policy review, surveyors examined the facility’s policies on LAWN Evaluation & Management – Leave of Absence without Notice, Wandering and Elopements, and Goals and Objectives, Care Plans. These policies required that residents at risk for leaving without notice be evaluated upon admission, that at-risk residents have care plans including strategies and interventions to maintain safety, and that care plans incorporate measurable, behaviorally stated goals and objectives derived from comprehensive assessments. The DON confirmed that these policies were not followed for the three residents with SUD, as their SUD-related risks, including potential exit-seeking behavior and withdrawal, were not addressed in their care plans.
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