Failure to Investigate Incident of Unknown Origin Involving Medication Impaction
Penalty
Summary
The facility failed to thoroughly investigate an incident of unknown origin involving a resident who was found to have more than 30 potassium chloride tablets impacted in the rectum. The resident, who was cognitively intact and required staff assistance with activities of daily living, was transferred to the hospital after experiencing nausea and loose stools. Hospital evaluation revealed numerous circular foreign bodies in the rectum, identified as potassium chloride tablets, and the resident denied inserting the medications himself. Upon return to the facility, there was no documented evidence that an investigation was initiated to determine the root cause of the incident or to rule out abuse, neglect, or mistreatment. The facility's Abuse Policy required that incidents of unknown origin be investigated as potential abuse until a root cause could be identified. However, there was no documentation of interviews or witness statements from staff who administered medications to the resident during the relevant period, nor was there an interview or written statement from the resident to assess for possible mistreatment. Additionally, the facility did not document any attempt to determine how the resident became impacted with the pills or whether any staff had harmed him or administered medication inappropriately. Subsequent to the resident's return, another incident occurred where multiple pills were found on the floor at the resident's bedside, and a facility investigation report was completed for this later event. However, the initial incident involving the rectal impaction of pills was not investigated in accordance with facility policy or regulatory requirements. The Director of Nursing and Nursing Home Administrator confirmed that a timely and comprehensive investigation was not conducted for the original incident.