F0609

D

Failure to Report Allegation of Neglect Involving Anti-Seizure Medication

Hamden, Connecticut Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency when it was identified. A resident with epilepsy, multiple sclerosis, repeated falls, and an adjustment disorder had a BIMS score of 7/15, indicating they rarely or never made decisions regarding tasks of daily living. An SBAR note documented that the resident experienced a seizure and was transferred to the ED after receiving Ativan per provider orders. A subsequent nurse’s note, written by the former DON, recorded that the resident’s family reported to hospital staff their concern that the facility had withheld the resident’s anti-seizure medications prior to the seizure event. This allegation of neglect was not entered into the facility’s grievance book, and there was no Accident and Investigation (A&I) documentation related to the allegation.

Review of the State Agency Reportable Events website showed no evidence that the allegation of neglect was reported to the State Agency around the time it was identified. The former DON acknowledged in interview that, despite documenting the family’s allegation in the nurse’s note and reviewing the Medication Administration Records, she did not report the allegation to the State Agency or fully investigate it. The Administrator stated that the former DON had only casually mentioned a medication issue and did not communicate that it was an allegation of neglect, and the Administrator was unaware of the nurse’s note. The facility’s Abuse Prohibition policy required immediate entry of allegations into the risk management portal, reporting to state and local authorities within specified time frames, and initiation of a documented investigation within 24 hours, but these steps were not carried out for this allegation.