Failure to Report Medication Error to State Agency
Penalty
Summary
The facility failed to report a medication error involving a resident with diagnoses of morbid obesity and Type 2 diabetes mellitus. According to the facility's Abuse Prohibition Policy, all allegations of abuse, neglect, or incidents resulting in serious bodily injury must be reported immediately or within specified timeframes. Despite this policy, the medication error was not reported to the State Agency as required. Record review showed the resident had active physician orders for Mounjaro (tirzepatide) and Emgality for diabetes and migraine prophylaxis, respectively. During an interview, the Administrator confirmed that the medication error was not reported and attributed the failure to high staff turnover, the Director of Nursing being on leave, the training of a new DON, and ongoing staffing instability at the time of the incident.