Failure to Prevent Resident Possession and Distribution of Marijuana Vape Pens
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety related to the use and distribution of marijuana products, resulting in accident hazards and inadequate supervision. One resident with schizophrenia, vascular dementia with behavioral disturbance, aphasia following cerebral infarction, and diabetes mellitus had moderately impaired cognition and required setup or cleanup assistance for ADLs. On one morning, staff found this resident standing in a puddle of urine, and later the same day, the resident was noted to have a change in mental status, difficulty ambulating, and was found on hands and knees urinating on the floor with a saturated bed, requiring assistance from three staff members. The resident was sent to the ED for confusion, where he was normally alert and oriented but had become altered; lab testing showed a positive urine drug screen for marijuana. Upon return to the facility that day, nursing documentation described the same resident sitting on the bed with pants removed, refusing clean clothing, being unsteady on his feet, and smiling or laughing at inappropriate times. A subsequent nursing note documented that this resident had obtained a vape pen from another resident, and the DON and physician were notified, with orders to monitor behavior closely. Interviews later confirmed that facility leadership was aware that the resident had possessed a marijuana vape pen belonging to another resident around the time of the altered mental status and incontinence episode, though it was unclear whether the pen had been taken or given. A second resident, with diagnoses including diabetes mellitus, bipolar disorder, obsessive compulsive disorder, traumatic subdural hemorrhage, and a history of TIA and cerebral infarction, had intact cognition but was dependent on staff for ADLs and had physician orders permitting independent LOAs for several hours per day. This resident had a behavior contract specifying that illegal or unauthorized substances were not permitted, all medications would be administered by staff, and that the resident agreed to follow facility rules, including adherence to smoking policies and allowing room searches. Nursing notes documented multiple LOAs with a nephew, and a late entry note indicated that the RDCS was notified that this resident had attempted to give another resident a vape pen, which nursing staff intervened to remove. Interviews with the ADON and RDCS revealed that this resident had an ongoing issue with possessing marijuana vape pens since around October, had previously had LOA privileges revoked due to drug use, and was believed to be the source of marijuana vape pens within the facility, including the pen obtained by the first resident. The facility’s policy prohibited residents from possessing or distributing illegal substances but did not define illegal drugs.
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