Failure to Investigate and Report Medication Error-Related Neglect
Penalty
Summary
Surveyors identified that the facility failed to thoroughly investigate and report allegations of neglect related to medication errors for two residents. The facility's policies required comprehensive investigation and reporting of incidents, including medication errors, to state and federal agencies. However, in both cases, the required steps were not followed, and there was no evidence that the incidents were reported to the New York State Department of Health as mandated. One resident with severe cognitive impairment and multiple psychiatric diagnoses did not receive a prescribed dose of clonazepam, despite documentation indicating it had been administered. The controlled drug record and pharmacy blister pack showed the medication was not removed or signed out on the date in question, and there was no progress note explaining the omission. The DON was informed of the discrepancy by staff, and the nurse involved was terminated, but there was no documentation of a thorough investigation or state reporting. Another resident, who had recently returned from the hospital with a peripherally inserted central catheter for IV antibiotics following a finger amputation due to infection, had multiple missed doses of ceftriaxone. The MAR showed several days where the antibiotic was not signed as administered, and the number of unused antibiotics matched the number of missed doses. The nurse responsible could not account for the missed administrations, and the DON noted irregularities in documentation. Despite the seriousness of the medication omissions, there was no evidence of a comprehensive investigation or required reporting to the Department of Health.