Failure to Conduct Thorough Investigations of Incidents and Medication Errors
Penalty
Summary
The facility failed to conduct thorough investigations into incidents involving accidents, potential abuse, neglect, and medication errors for several residents. In multiple cases, investigations lacked comprehensive documentation, including missing or incomplete witness statements, insufficient details about the circumstances of the incidents, and failure to determine the root cause or contributing factors. For example, after a resident with Alzheimer's dementia was found on the floor with a head injury, the investigation did not include statements from the assigned nursing assistant, lacked information on the resident's care prior to the fall, and omitted a summary of the incident's cause or necessary corrective actions. Additionally, post-fall monitoring was incomplete, and the incident was reported late to the state. Another resident with multiple sclerosis and severe cognitive impairment experienced multiple falls, yet investigations did not include statements from all relevant staff, failed to assess environmental or equipment factors, and did not address whether care plan interventions were implemented. In one case, a resident was found on the floor after their wheelchair rolled back during a haircut, but the investigation did not review the wheelchair's condition or the environment. In another, a resident with significant cognitive impairment was found on the floor in the dining room, but the investigation did not address positioning or follow-up care. The facility also failed to thoroughly investigate a medication error involving duplicate orders for Alendronate, resulting in the resident potentially receiving double doses. The investigation did not verify the number of tablets dispensed by the pharmacy, nor did it determine how the duplicate order was entered without system or pharmacy alerts. Across all incidents, there was a consistent lack of comprehensive review, failure to identify involved staff, and absence of summaries detailing the who, what, where, when, and how of each event, as well as missing documentation of whether care plans were followed.