Failure to Implement Care Plan Monitoring for Withdrawal Symptoms
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan for one resident. The facility’s RAI and Comprehensive Care Plans Policy required that care plans be developed and implemented consistent with each resident’s specific condition, risks, and needs. Resident #42, admitted with diagnoses including other stimulant use, depression, and nutritional deficiency, had a care plan revised on 10/13/25 that directed staff to monitor and document for potential signs of withdrawal, including respiratory distress, cardiac decompensation, nausea/vomiting, anxiety, hostility, bloodshot eyes, pinpoint pupils, and diaphoresis. Record review showed no documentation that staff monitored for or recorded any signs or symptoms of withdrawal as required by the care plan, and on 2/20/26 the Resource Nurse confirmed that the resident’s record did not include monitoring for withdrawal symptoms. This failure to carry out the care plan’s specified monitoring for withdrawal constituted noncompliance with the facility’s policy and the requirement to implement a comprehensive care plan according to the resident’s identified needs.
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