Failure to Prevent Access to Alcohol for Resident With Known Alcohol Abuse History
Penalty
Summary
The deficiency involves the facility’s failure to monitor and supervise a resident with a known history of alcohol abuse, allowing the resident to obtain and consume alcohol on two separate occasions, resulting in hospitalizations. The resident was admitted with diagnoses including alcohol abuse, opioid abuse, bipolar disorder, schizoaffective disorder, hypertension, acute kidney failure, and acute respiratory failure. The resident’s care plan identified a history of substance abuse/chemical dependency, including opioid abuse and alcohol use, and included an intervention to establish a behavioral contract and ensure the resident was aware of rules prohibiting alcohol and illicit substances. The facility’s house rules also stated that drug and alcohol use were strictly prohibited and that illegal or non-prescribed drugs or alcohol may not be brought into the premises. On one occasion, a progress note documented that while an LPN was passing medications, a CNA called out after nearly finding the resident on the floor. The resident’s room was in disarray, and upon assessment, the resident was drowsy and disoriented, with vital signs within normal limits. As the LPN moved the call light closer to the resident, an empty bottle of brandy wine was found on the bed. When asked where the bottle came from, the resident became upset, used profanity, and later came to the nurse’s station and threw a shoe at staff. The resident was sent to the hospital, where records showed diagnoses of alcohol intoxication, aggressive behavior, and chronic tremor, and the hospital physician attributed the aggressive behavior to alcohol intoxication. On a later occasion, another progress note documented that staff were informed the resident had alcohol in his room under his pillow. An LPN went to the room and found a liquor bottle under the resident’s cover. After the bottle was removed, the resident noticed it was gone, went to the nurse’s station where his roommate was standing, and began arguing, shouting, and cursing at the roommate, refusing to calm down when asked. Hospital records from this second episode again documented admission for aggressive behavior, alcohol intoxication, chronic tremor, hypertension, hypothyroidism, and COPD. Interviews indicated that the facility did not know how the resident obtained alcohol in the first incident, and that in the second incident the alcohol had been purchased for the resident by a staff member, despite facility rules and the resident’s documented alcohol abuse and care plan interventions.
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