Failure to Report Medication Error and Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of potential abuse and/or neglect to the State Agency as required, following a medication error involving a resident with severe cognitive impairment and multiple medical conditions, including dementia, diabetes, sleep apnea, and anxiety. The resident required extensive assistance with daily activities. On the day of the incident, a medication error occurred when a psychotropic medication was administered via injection after the resident refused the oral form, due to a transcription error by a registered nurse who failed to enter the new order correctly into the electronic health record. The resident's representative expressed multiple complaints regarding care, including medication management and provider oversight, during a meeting with facility leadership. Despite these complaints and the medication error, facility staff did not generate or report an allegation of abuse or neglect to the State Agency. Interviews with facility staff revealed that the incident was considered a transcription error with no negative effect on the resident and was therefore not reported. However, the Director of Nursing later confirmed that administering a psychotropic medication as an injection constituted a chemical restraint, which is a form of abuse, and acknowledged that the incident should have been reported. The administrator also confirmed awareness of the incident and the complaints but did not report them.