Failure to Investigate Medication Error Incident
Penalty
Summary
The facility failed to thoroughly investigate a medication error incident involving one resident who was admitted with a fistula of the vagina to the small intestine and an ileostomy. The resident experienced diarrhea and elevated creatinine, for which a physician ordered a one-time intravenous administration of 1 liter of normal saline. Review of the Medication Administration Record (MAR) showed no documentation that the IV normal saline was administered, and the facility's incident reporting logs did not reflect a medication error for this resident. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed that no incident report or investigation was initiated regarding the potential medication error. Staff acknowledged that, according to facility policy and state guidelines, an investigation should have been conducted to determine the circumstances and cause of the incident. The lack of investigation left unanswered questions about the occurrence and whether it was related to neglect or unmet care needs.