Failure to Report and Investigate Alleged Medication Misadministration and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect related to the suspected administration of medications without physician orders. Multiple staff members observed an LPN pre-pouring Tylenol PM and melatonin into medication cups for residents, despite no residents having orders for these medications. Staff statements indicated that the LPN routinely prepared these medications in advance and that concerns were reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). However, there was no documentation that these allegations were investigated at the time they were reported. Further review revealed that the incidents were not reported to the state agency as required by facility policy and federal regulations. The ADON and DON were both made aware of the allegations, but failed to initiate a thorough investigation or notify the Administrator in a timely manner. There was no evidence of resident or staff interviews, resident assessments, or monitoring for potential adverse medication reactions related to the alleged incidents. The facility's own policies required immediate reporting and investigation of such allegations, but these procedures were not followed. The failure to report and investigate these allegations had the potential to affect 38 residents residing on one unit. The facility census at the time was 87. The Administrator confirmed that the incidents were not reported to the state agency and that there was no documentation of a completed investigation, including interviews or assessments of potentially affected residents.