Administrative Failures Lead to Neglect and Medication Error Resulting in Resident Death
Penalty
Summary
Facility administration failed to provide effective oversight, policy enforcement, and resource allocation, resulting in multiple deficiencies that compromised resident safety and well-being. Specifically, the facility did not ensure proper use of its resources, including staff, policies, and communication systems, to protect a resident. Deficiencies cited include failure to prevent neglect, significant medication errors, lack of resident dignity, failure to report adverse events to the State Survey Agency, and failure to meet professional standards of care. The facility also failed to ensure that the medical director fulfilled their responsibilities and that resident care was properly supervised by a physician. These failures collectively contributed to a medication error involving morphine sulfate, which was transcribed as a scheduled dose instead of as needed, and this error was not promptly identified or addressed. Interviews revealed that key leadership, including two Directors of Nursing and the Administrator, were unaware of the circumstances surrounding the resident's decline and death, and did not recall being notified or involved in the incident investigation. The Administrator attributed the medication error to confusing hospice orders and staff overstimulation, and stated that errors were reviewed only after the incident. The Medical Director acknowledged the event as a significant medication error, with family communication occurring later. The Administrator also indicated that guidance was sought from the Executive Director and Medical Director regarding reporting the incident to the State Department of Health, and was advised not to report it. These actions and inactions resulted in the facility's failure to ensure resident safety and compliance with regulatory requirements.