Failure to Investigate and Report Allegation of Withheld Anti-Seizure Medication
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report an allegation of neglect related to a resident’s anti-seizure medication. The resident had diagnoses including epilepsy, multiple sclerosis, repeated falls, and adjustment disorder, and a BIMS score of 7/15 indicating significantly impaired decision-making for daily tasks. An SBAR note documented that the resident experienced a seizure and was transferred to the ED with new orders for IM Ativan. A subsequent nurse’s note by the former DON, based on the hospital record, stated that the resident’s family reported to hospital staff concerns that the facility had withheld the resident’s anti-seizure medications. The DON documented that she reviewed the resident’s October and November MARs. However, there was no corresponding grievance or documentation in the facility’s Grievance Book related to the family’s allegation that seizure medications were withheld, and no Accident and Investigation (A&I) report was available despite being requested. Review of the State Agency Reportable Events website showed no evidence that the allegation of neglect was reported to the State Agency. In an interview, the former DON acknowledged she did not report the allegation to the State Agency or fully investigate it beyond reviewing the MARs, explaining that the family had only reported the concern to hospital staff and not directly to the facility. The Administrator reported that the DON had only casually mentioned a medication issue and had not communicated that it was an allegation of neglect, and the Administrator was unaware of the DON’s nurse’s note. These actions and omissions were inconsistent with the facility’s Abuse Prohibition policy, which required prompt reporting to authorities and initiation of a documented investigation upon receiving information about suspected or alleged abuse or neglect.
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