Failure to Thoroughly Investigate Medication Error and Potential Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an unusual occurrence involving a potential medication error and possible neglect when a resident with severe cognitive impairment was found to have received unprescribed substances, including opiates and barbiturates, as evidenced by a positive urine drug screen during a hospital stay. The resident, who had a documented allergy to gabapentin and no orders for opiates, was administered her roommate's medications in error on a previous occasion, and subsequently experienced a significant change in condition, including lethargy, low respiratory rate, and hypoxia, leading to hospital admission and administration of Narcan. Despite these events, the facility's investigation into the incident on the day of the resident's hospital transfer was incomplete and lacked critical documentation. The investigation did not include statements from key staff members who were on duty or may have cared for the resident at the time of the incident, nor did it include statements from emergency medical services staff who transported the resident to the hospital. Additionally, the resident's roommate, who was a potential witness and had relevant information regarding the medication administration, was not interviewed or included in the investigation. The facility also failed to collect statements from the resident or her representative, despite the resident's ability to answer yes/no questions, and did not document who completed the resident questionnaires or when they were completed. Interviews with facility staff revealed a lack of clarity regarding who was spoken to during the investigation, and the Director of Nursing and Administrator could not confirm which staff had been interviewed, as no statements were collected. The facility's policy required a reasonable investigation of all alleged violations involving abuse, neglect, or injuries of unknown origin, but the investigation into this incident did not meet those standards, as it lacked essential documentation and failed to include pertinent information from staff, residents, and witnesses directly involved in or knowledgeable about the event.