Failure to Timely Report Medication Error and Potential Neglect
Penalty
Summary
The deficiency involves the facility’s failure to timely report an incident of potential neglect to the state survey agency after a resident received the wrong medications, required Narcan, and was hospitalized. The facility’s abuse prevention policy defines possible neglect as the failure to provide goods or services necessary to avoid physical harm, pain, mental anguish, or emotional distress, or that could reasonably be expected to cause pain, injury, or death. The resident involved was admitted with orthostatic hypotension and a neurocognitive disorder with Lewy bodies, and had a BIMS score of 14/15, indicating intact cognition, with an activated power of attorney for health care. On the date of the incident, a licensed nurse administered medications intended for another resident, including Oxycontin ER 20 mg and Amlodipine 5 mg, to this resident. The physician was contacted immediately, Narcan was ordered and administered, and the resident was sent to the emergency department for observation of the medication error. In the hospital, the resident was found to be markedly orthostatic and received IV electrolytes and hydration, and was later transferred to another hospital when blood pressure began trending low, before eventually returning to the facility. During an interview with the surveyor, the DON stated the incident was not reported to the state agency because it was the nurse’s first medication error and there were no noted signs or symptom effects of receiving the wrong medication, and acknowledged that the 5-day investigation was not submitted within the required 5 days.
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