Failure to Report Medication Error and Misappropriation of Resident Medications
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property were reported immediately, but not later than 24 hours, to the administrator and appropriate authorities as required. Specifically, a medication error occurred when a resident was discharged and was mistakenly sent home with four medications belonging to another resident. The error was discovered after the discharged resident was seen at home by a VA nurse, who found the incorrect medications and confirmed they had not been taken. The medications were subsequently destroyed by the VA nurse. Interviews and record reviews revealed that the medication error was not reported to the State Survey Agency as required by regulation. The facility administrator stated that regional staff advised that reporting the incident was unnecessary, resulting in a failure to follow established procedures for reporting such incidents. The affected residents included one with intact cognition and another with severe cognitive impairment, both with significant medical histories. The facility's policy required verification of medications sent home with residents, which was not followed in this instance.