Incomplete Investigation of Medication Found at Resident's Bedside
Penalty
Summary
The facility failed to conduct a thorough investigation regarding an incident involving a resident, identified as Resident R77, who was found with two cups of medication at their bedside. The facility's policy on abuse, neglect, and exploitation requires thorough investigation and reporting of such incidents, but the investigation was incomplete. The clinical record of Resident R77, who has diagnoses of renal insufficiency and diabetes mellitus, indicated that the medications were found on an unspecified date, and the facility's documentation did not include necessary details such as the identification of the pills, their origin, or whether they were documented as taken by the resident. The Director of Nursing confirmed that the investigation was incomplete, acknowledging the lack of documentation and interviews with staff from various shifts. The facility did not determine what the medications were, where they came from, or if they were part of the resident's prescribed regimen. This failure to conduct a thorough investigation is a violation of the facility's responsibility to ensure resident safety and comply with regulatory requirements.
Plan Of Correction
An incident report will be filed in our internal risk master system regarding the medications being found at the bedside for resident R-77. The resident's provider was also made aware. If possible, it will be determined if the medications were facility based or were previously in the possession of the resident. The Medication administration record will be reviewed for accuracy and staff interviews conducted to possibly learn the origin of these medications. No untoward effects were demonstrated by the resident at the time of discovery. All incidents will be reviewed on an at least weekly basis by the DON and/or NHA to ensure timely and complete submission of all pertinent facts. Incidents will be reviewed more immediately if the situation is more acute. Nursing staff (RNs, LPNs and Unit Managers) will be educated by the Director of Nursing, Staff Educator or designee on the gathering of all pertinent information as part of the investigation of incidents including complete and accurate documentation of medication administration, and that nursing staff are not permitted to leave medication at the bedside unless directed by the provider and included as part of the care plan. Seven rooms will be checked for medications left in the resident's rooms per week for three weeks and then seven rooms will be checked every two weeks for a period of three weeks. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.