Failure to Conduct Thorough Investigations of Incidents and Medication Error
Penalty
Summary
The facility failed to conduct thorough investigations for two residents involved in separate incidents, including a resident-to-resident altercation and a medication error. For the altercation, the investigation did not document that both residents were placed on alert charting for monitoring after the incident, despite facility protocol and staff statements indicating this should have occurred. Additionally, the investigation lacked comprehensive details regarding the circumstances and actions taken immediately following the event. In the case of the medication error, the investigation for one resident did not include staff statements or a root cause analysis to determine how abuse or neglect was ruled out. The resident involved had significant medical conditions, including intracranial hemorrhage, cerebral infarction, hemiplegia, and a legal guardian responsible for their care. The investigation also failed to document the process for discontinuing a medication as requested by the responsible party, and the medication was not discontinued in a timely manner. These omissions resulted in incomplete investigations that did not meet the requirements outlined in state guidelines.