Failure to Timely Report Medication Error and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting to the state agency (SA) regarding two separate incidents: a significant medication error and a resident-to-resident abuse event. In the first case, a resident with a care plan for high-risk pain medications received both oxycodone and morphine, resulting in altered mental status, hypoxia, and hospital admission for opioid overdose and aspiration pneumonia. The medication error was not reported to the SA until the day after the incident, as the DON delayed reporting while further investigating the significance of the error, despite facility policy requiring immediate reporting of significant medication errors. In the second case, two residents with dementia were involved in a physical altercation resulting in injuries, including a bump on the head and facial bruising. The incident occurred in the morning, but was not reported to the SA within the required two-hour timeframe. The DON acknowledged the delay, stating she reported the incident as soon as she was able after being notified by staff. Facility policy mandates immediate reporting of suspected abuse or incidents resulting in serious bodily injury, but this protocol was not followed in either event.