Failure to Prevent Family from Performing Unauthorized Medical Procedure
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident from neglectful treatment by not intervening when family members performed unauthorized medical procedures. The resident, a female with a history of seizures, stroke, legal blindness, and malnutrition, was dependent on staff for activities of daily living and had impaired communication and vision. Despite being on hospice care, her family members, including a physician, brought in supplies and inserted an intravenous (IV) line into her right neck without orders from her primary doctor or hospice. Staff observed IV fluids hanging from an IV pole but did not witness the administration of fluids. The family member who inserted the IV was later trespassed from the facility by the administrator and police. Prior to this incident, another family member impersonated a hospice director and attempted to give medication orders for the resident, which were not accepted after staff verified her credentials. On the day of the IV incident, staff were made aware by hospice that a family member might attempt to start an IV. The unit manager spoke with the family member, who insisted on starting the IV despite being told that IV therapy would require hospital transfer. The family proceeded to insert the IV after the unit manager left the room. Staff became aware of the IV placement after the fact, and there was a delay in notifying the director of nursing (DON) and in sending the resident to the hospital. During this time, the family kept staff out of the room, and the IV was removed before emergency services arrived. Documentation and interviews revealed inconsistencies in staff reporting and delays in escalating the situation to facility leadership. The resident was eventually transferred to the hospital for evaluation, but the delay in intervention and failure to prevent the unauthorized medical procedure constituted neglect. The facility's policy required protections against abuse and neglect, but staff did not act promptly to prevent or stop the family from performing the procedure or to ensure the resident's immediate safety.