Failure to Report and Investigate Alleged Neglect of Medication Administration
Penalty
Summary
The facility failed to follow its policies and procedures regarding the reporting of alleged neglect when two residents, including one identified as R8, complained during a resident council meeting about not receiving their afternoon medications. The Abuse Prevention Program Policy requires that all alleged or suspected violations, including neglect, be reported immediately to the Administrator or Director of Nursing, and subsequently to the State Survey Agency and other authorities as required by law. However, after the resident council meeting where the complaints were raised, there was no immediate follow-up or investigation into the allegations, and the incident was not reported to the State Agency as required. Interviews revealed that the Director of Nursing received the grievances but did not confirm the identity of one of the residents or conduct a full medication review. The Nursing Home Administrator was initially unaware of the complaints and later stated that the residents' anonymity was maintained due to fear of retaliation, resulting in no direct questioning or investigation of the residents involved. There was also no documentation of a medication review for the affected residents, and the agency nurse who was on duty at the time of the alleged neglect had not been interviewed regarding the incident. These actions and inactions led to the deficiency cited in the report.