Failure to Notify Physician of Resident’s Suspected Illicit Drug Paraphernalia
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of suspected illegal drug paraphernalia found in a resident’s possession, contrary to its own Notification of Change policy. The policy, dated 06/2025, required prompt notification of the resident, physician, and representative when there is an accident involving the resident that results in injury or has the potential for requiring physician intervention, with all notifications documented in the medical record. Resident #7 was admitted with diagnoses including alcohol abuse with withdrawal, cannabis use, other stimulant dependence, and other psychoactive substance abuse, and had a BIMS score of 15 indicating cognitive intactness. On 02/17/26, the care plan team and administrator met with the resident and in-serviced them regarding revocation of self sign-out privileges due to non-compliance with facility rules related to smoking devices and paraphernalia, which the resident acknowledged and signed as understanding. A subsequent nurse’s note dated 02/24/26 documented that on 02/17/26 the resident had received education about revocation of self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and that the resident continued to use illicit substances and was reported to provide substances to other residents despite prior education. There was no documentation that the physician was notified of the illicit paraphernalia found on 02/17/26. The resident later stated that a methamphetamine pipe had been found in their room in February, confiscated, and thrown in the trash. The HK supervisor reported that housekeeping observed the resident place a small glass pipe with residue in a box, notified the administrator, and then accompanied the administrator to the resident’s room, where the resident handed over the suspected drug paraphernalia, which was disposed of in the trash. The medical director confirmed they were not notified of the suspected drug paraphernalia, and the DON and administrator both stated that physician notification was not documented or completed.
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