Failure to Report Nurse Abandonment and Missed HS Medications to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse and neglect to the State Survey Agency and other required officials after an agency LPN left mid‑shift without notice, resulting in missed medication administration for 13 residents. On the evening in question, the LPN worked approximately the first two hours of a 7 PM to 7 AM shift, then left the building without informing leadership or giving report to another nurse, locking the medication cart keys in the medication room. Certified nurse aides later noticed the keys in the medication room and, around midnight, notified the on‑call nurse. A replacement RN from the agency arrived around 3:30 AM and confirmed that none of the HS medications for a group of rooms had been administered and that, by the time of review after 4 AM, it was too late to give the medications. Facility records, including the Summary of Medication Errors and individual medication error reports, documented that 13 identified residents did not receive their scheduled HS medications due to the LPN’s failure to pass medications and subsequent departure. The facility’s Investigation Summary categorized the event as potential neglect related to medication administration delay but concluded it did not meet criteria for reportable neglect, and therefore did not report the allegation to the State Survey Agency or to the State’s nurse licensing department at the time of the incident. The Nursing Home Administrator confirmed during interview that the LPN left mid‑shift without notice, that 13 residents did not receive their HS medications, and that the facility did not notify the State Survey Agency or the nurse licensing department as required by its abuse policy. The facility’s abuse policy required all allegations involving abuse or neglect to be reported immediately (within two hours if involving abuse or serious bodily injury, and within 24 hours if not) to the State Survey Agency and other officials. Despite this policy and the documented missed medications for multiple residents, the facility determined the event was not reportable and did not make timely reports to the appropriate authorities.
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