Failure to Address Impaired Nurse and Missed Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that care and services were provided in accordance with professional standards of practice, comprehensive resident assessments, and physician orders when an LPN worked while appearing to be under the influence of an illegal substance and continued to provide resident care. Multiple residents and staff reported that on 02/22/26 the LPN appeared disheveled, very tired, was falling asleep while standing, dozing off mid-conversation, and acting "weird" or erratic. Residents reported that medications were administered late, that some medications were not received at all, and that at least one resident’s pain medication was administered after being dropped on the floor. One resident reported that the LPN entered her room and fell asleep on her bed. Another resident reported not receiving any medications that day. Staff interviews showed that concerns about the LPN’s behavior were repeatedly reported to the on-call manager, another LPN, but were not escalated to the DON or Administrator on the day of the incident. The on-call LPN stated she contacted the DON and was instructed to call and speak with the LPN in question, who reported being tired from lack of sleep; no further direction was reported. The DON later stated she was not made aware of the extent of the erratic behavior on that date, and the LPN completed the full shift on 02/22/26 and returned to work the following day, working part of another shift before residents’ complaints prompted further action. Residents and staff reported that during this period, residents did not receive medications, tube feedings, treatments, and other interventions as ordered. The facility’s own self-reported incident documentation confirmed that residents had reported the LPN was dropping pills and appeared to be under the influence of an unknown substance, and that the on-call LPN did not report the incident to the Administrator at the time. The LPN later tested positive for cocaine. The investigation documentation showed that not all residents were assessed for possible negative effects related to the incident, and statements were not obtained from all affected residents. Facility staff, including an RN and the DON, verified that the investigation was not completed thoroughly, that there was no evidence of a QAPI meeting related to the incident, and that the Medical Director was not notified until several days after the event. These actions and inactions occurred despite facility policies and resident agreements requiring protection of resident rights, provision of adequate and appropriate medical and nursing care, prohibition of illegal drug use, and immediate, thorough investigation and reporting of suspected abuse or neglect.
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