Failure to Timely Report Medication Error and Resulting Injury
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent neglect by not ensuring that all alleged violations involving neglect were reported immediately, as required. Specifically, a significant medication error occurred when a resident received twice the ordered daily dose of donepezil, a medication for dementia, which led to worsening confusion and necessitated hospitalization. The error was discovered after the resident exhibited a decline in mental status, but the incident was not reported to the appropriate state authorities (HHSC) within the required two-hour timeframe after discovery. The resident involved had a history of advanced dementia, metabolic encephalopathy, and muscle weakness, and was at risk for falls and harm as documented in her care plan. Medical records showed that the resident's donepezil dosage was increased in error, and the medication administration record included a warning that the frequency exceeded the usual daily dose. Despite these indicators and the resident's subsequent hospitalization for altered mental status, the facility did not report the medication error and resulting injury as required by policy and regulation.