Failure to Timely Report Potential Abuse/Neglect After Medication Error
Penalty
Summary
Facility staff failed to report an incident of potential abuse or neglect within the required timeframe after a resident received medications not prescribed to them, resulting in the resident being sent to the emergency room. The incident involved a registered nurse administering three medications—tizanidine, cyclobenzaprine, and diphenhydramine—belonging to another resident, with documentation indicating that the nurse was aware these medications were not ordered for the resident. The facility's policy requires immediate reporting of suspected abuse or neglect to the Administrator and Director of Nursing, but this was not followed, as the incident was not reported to the appropriate authorities within the mandated two-hour window. Record review and staff interviews revealed that only nursing staff received education on abuse and neglect reporting, while other departments such as food service and housekeeping had not received recent training on these requirements. The Director of Nursing confirmed that the lack of timely reporting was due to nursing staff not notifying leadership as required, and acknowledged that all staff should be included in abuse and neglect reporting education. The surveyor found no evidence of education provided to non-nursing departments regarding these reporting obligations.