Failure to Conduct Thorough Incident Investigations Involving Medication Errors
Penalty
Summary
The facility failed to conduct thorough investigations for three out of four residents reviewed for incident investigations, as required by both facility policy and regulatory guidelines. In each case, the investigations did not include interviews with other residents assigned to the staff involved in the incidents, nor did they document whether abuse or neglect was ruled out. The facility's policy and the referenced guidelines require systematic evidence collection, including interviews with all involved parties, to determine if abuse, neglect, or misappropriation occurred and to prevent recurrence. For one resident with severe cognitive impairment and on hospice care, a scheduled dose of morphine was not administered, and the responsible RN was unaware of the missed dose. The investigation did not include interviews with other residents assigned to that RN. Another resident, also with severe cognitive impairment and on hospice, missed several doses of a pain medication on multiple days when cared for by different contract RNs. Although the staff involved were interviewed, there was no documentation of interviews with other residents those staff cared for, despite a collateral contact reporting an attempted medication error by an unknown contract nurse. A third resident, with intact cognition and a history of gout, received the wrong dose of oxycodone from another resident's supply. The investigation included a statement from the responsible RN but did not document whether the resident was informed of the error or if other residents assigned to that RN were interviewed. The Health Services Director confirmed that interviews with other residents were not documented, and in some cases, not conducted, particularly for non-interviewable residents. These omissions were contrary to both facility policy and regulatory requirements.