Failure to Investigate and Educate Staff After Medication Error
Penalty
Summary
The facility failed to thoroughly investigate and provide staff education following a medication error involving a resident who was admitted with multiple complex diagnoses, including intraspinal abscess, sepsis, and chronic myeloproliferative disease. The resident was inadvertently administered the wrong intravenous medication, Cefepime HCl, instead of the ordered Daptomycin. Documentation shows that the error was identified, the physician and family were notified, and neuro checks were initiated, but there was no evidence of adverse reactions at the time. However, the facility's progress notes lacked a follow-up entry for the day after the incident. Interviews revealed that the investigation into the medication error was incomplete. The DON, who was new to the position, provided only one investigation statement from the LPN involved and acknowledged that the form was not filled out correctly. The DON also stated that there was no proof that staff education on the seven rights of medication administration had been provided at the time of the incident. Other staff members confirmed that they had not received formal education related to medication rights or incident response until much later. The facility's policy requires immediate and thorough investigation of alleged neglect, including obtaining statements from all involved staff and providing education to prevent recurrence. In this case, the investigation did not include statements from all relevant staff, and there was no documentation of timely staff education. The lack of a comprehensive investigation and staff training following the medication error constituted a failure to respond appropriately to an alleged violation, as required by facility policy.