Failure to Investigate Alleged Unauthorized Medication Administration
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect related to the administration of Tylenol PM without physician orders on two separate occasions. On the first occasion, a nurse was observed pre-pouring Tylenol PM and melatonin into medication cups for multiple residents, despite no physician orders for these medications. This incident was reported to the Assistant Director of Nursing (ADON), who in turn notified the Director of Nursing (DON), but no investigation was documented, and the allegations were not reported to the state agency as required by facility policy. The nurse in question continued to work on the unit for several days following the initial report. A second incident involved another nurse observing the same LPN preparing and placing Tylenol PM in medication cups for several residents. The nurse took photographs and reported the incident to the ADON, who removed the medication from the cart but did not ensure a thorough investigation or resident monitoring. Interviews with staff and residents revealed that some residents recalled receiving Tylenol PM without an order, while others were unaware. There was no documentation of resident assessments, monitoring for adverse reactions, or pharmacy notification. The facility's own policies required immediate reporting, thorough investigation, and resident assessment, none of which were completed. The deficiency affected up to 38 residents on one unit, many of whom had complex medical and psychiatric diagnoses, including diabetes, bipolar disorder, schizophrenia, and anxiety. Despite multiple staff members reporting concerns about the LPN's medication practices, facility leadership failed to conduct a comprehensive investigation, interview all potentially affected residents and staff, or document any monitoring or assessment for possible adverse effects. The lack of action and documentation directly violated the facility's abuse prohibition and medication administration policies.