Failure to Investigate and Prevent Neglect Following Missed Medication Administration
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that measures were taken to prevent further incidents while an investigation was in progress. Specifically, a non-verbal female resident with multiple diagnoses, including seizure disorder, dementia, and intellectual disabilities, was not administered her prescribed anticonvulsant medication (Levetiracetam) as ordered. The resident's care plan required strict adherence to medication administration and documentation of seizure activity, but there was a lapse in ensuring the medication was given as prescribed. On a specific date, an LVN reported to the DON a suspicion that a medication aide was not administering the resident's Keppra as ordered, based on a low medication level. The DON did not immediately report the allegation to the Administrator or initiate an investigation. Instead, the DON instructed the LVN to gather more evidence by monitoring the medication bottle and delayed any intervention until several days later, when audits of anticonvulsant medication administration were initiated. During this period, the resident experienced a seizure, which was observed and documented by the LVN, including a drop in oxygen saturation and loss of consciousness. Interviews revealed that the Administrator, who served as the Abuse Coordinator, was informed of the suspicion but did not recall being told what immediate actions would be taken to protect the resident. The facility did not immediately initiate an investigation or implement protective measures for the resident or others potentially at risk. The delay in reporting and investigating the allegation, as well as the lack of immediate interventions, constituted a failure to respond appropriately to an alleged violation of neglect.