Failure to Investigate and Protect Resident After Medication Error Allegation
Penalty
Summary
The facility failed to thoroughly investigate and protect a resident following an allegation of neglect related to a medication error. A resident with intact cognition and multiple diagnoses, including hypertension, atrial fibrillation, anemia, and depression, was discharged from the transitional care unit and later attended a clinic appointment. During this appointment, it was discovered that the resident had been given bubble medication cards at discharge, some of which contained medications prescribed for another resident. The resident reported taking these medications at home, which included a blood pressure medication, and had experienced falls and a recent hospitalization for low blood pressure. The incident was reported to the facility by an external clinic, and staff interviews confirmed that the information was relayed to a nurse and then to the nurse manager. However, a review of the resident's electronic health record revealed a lack of documentation regarding any investigation into the reported medication error. Staff acknowledged that the incident should have been reported to the state agency and that an investigation should have been initiated immediately upon learning of the event, but this did not occur. The facility's own Abuse and Neglect policy requires immediate reporting, assessment, and investigation of any allegations of abuse, neglect, or misappropriation of resident property. The policy outlines specific steps for protecting residents and notifying appropriate agencies, but these procedures were not followed in this case. The failure to initiate an investigation and ensure resident protection constituted a deficiency in responding to the reported allegation of neglect.