Failure to Promptly Investigate and Resolve Resident Grievance Regarding Medication Administration
Penalty
Summary
A resident with a history of left pubic fracture, type 2 diabetes mellitus, major depressive disorder, and chronic pain, who was cognitively intact, reported a grievance regarding medication administration. The resident expressed concerns that a nurse attempted to administer medications in a manner she was uncomfortable with and that one of the medications appeared unfamiliar. Upon questioning, the nurse took the medications back to the med cart and returned with the correct ones. The resident reported this incident to the Social Services Director (SSD), who initiated a grievance process. The facility's grievance policy requires that grievances be routed to the appropriate department head, investigated thoroughly, and that the resident be provided with a verbal follow-up including details of the investigation and its resolution. However, the investigation into the resident's grievance lacked documentation of interviews with staff or other residents, aside from the SSD's interview with the complainant. There was also no written communication of the grievance resolution provided to the resident, and the facility did not obtain a signature from the resident or representative indicating agreement or disagreement with the outcome. Interviews with facility leadership revealed that the nurse attempted to administer Tylenol instead of the resident's scheduled hydrocodone-acetaminophen due to the unavailability of the prescribed medication, despite the resident not having an order for Tylenol. The facility did not conduct interviews with other staff or residents regarding the incident, and there was no comprehensive documentation of the investigation or follow-up with the resident as required by policy.