Failure to Conduct Thorough Investigations into Alleged Neglect and Medication Errors
Penalty
Summary
The facility failed to initiate thorough investigations into allegations of neglect for two residents. For one resident with a history of epilepsy and anxiety disorder, the family reported that after a hospital stay, the resident was discharged with a 30-day order for Keppra, an anti-epileptic medication. The facility did not continue the Keppra order after the initial 30 days, and this lapse was not identified by staff but was instead brought to their attention by the resident's family. Review of the clinical records confirmed that Keppra was not ordered or administered for several months, and the facility's investigation into this medication error lacked a summary of findings, witness statements, relevant discharge summaries, and documentation explaining how the error occurred or why it persisted undetected. For another resident with dementia, anxiety disorder, and hypothyroidism, a medication error occurred when the resident was administered medications intended for another resident, including Trazodone, Senna, Zyprexa, and Tramadol. The incident was documented in a progress note and an incident report, but the documentation lacked critical details such as a witness statement from the LPN responsible, an interview with the affected resident, identification of whose medications were given, assessment of whether other residents were affected, and a root cause analysis or corrective action plan. Interviews with the DON and ADON confirmed that the facility did not conduct thorough or complete investigations into these incidents. The facility's failure to follow its own policy for investigating allegations of neglect and medication errors resulted in incomplete documentation and a lack of understanding of the circumstances and causes of the incidents.