Failure to Report Potential Neglect After Unprescribed Controlled Substances Found in Resident
Penalty
Summary
The facility failed to report an unusual occurrence involving potential neglect to the Indiana Department of Health (IDOH) when a dependent resident was found to have unprescribed controlled substances in her system during a hospital stay. The resident, who had diagnoses including unspecified dementia, hypertension, asthma, convulsions, and heart failure, was severely cognitively impaired and required staff assistance for daily activities. Her prescribed medications did not include opioids or barbiturates, and she was allergic to gabapentin. During a hospital admission for altered mental status, the resident was found to have a low respiratory rate, hypoxia, and low blood pressure. A urine drug screen was positive for barbiturates and opiates, and she required Narcan administration for suspected opioid overdose. Despite concerns from emergency medical services and the resident's family about a possible medication mix-up with her roommate's medications, the facility did not report the incident to IDOH. The Director of Nursing indicated that the event was not reported because no medication error was identified by the night shift nurse, and the facility believed it had followed IDOH guidelines for reporting potential neglect. However, facility policy required immediate reporting of all alleged violations involving abuse, neglect, or mistreatment, regardless of whether a medication error was confirmed.