Failure to Investigate Alleged Resident Ingestion of Staff Medication
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete and thorough investigation to rule out neglect after an allegation that a resident ingested a staff member’s medication. The facility’s Abuse, Neglect, and Exploitation Prevention Policy required immediate protective measures, factual documentation of incidents, leadership notification, initiation of an investigation by the administrator or designee, external reporting as needed, and updating care plans with interventions to prevent recurrence. Resident R8 had multiple diagnoses, including CHF, epilepsy, schizophrenia, intellectual disability, cognitive communication deficit, anxiety, and psychosis. A nursing note documented that at approximately 6:30 a.m., a nurse aide reported her pocketbook missing from the nursing station, and a licensed nurse later found the pocketbook and other personal belongings in the resident’s possession, with documentation that the resident had ingested Zofran 4 mg from the pocketbook. During interviews, the licensed nurse confirmed that the nurse aide stated she knew the resident had taken the pocketbook because the resident was “just taking things.” The nurse and aide located the resident in either the dining room or the resident’s bedroom, retrieved the pocketbook, and the aide reported that her keys, money, and Zofran were missing. The nurse reported that empty blister packs from the Zofran prescription were found in the resident’s room trash can, and that the resident denied taking the pocketbook, money, keys, and medication, although at one point the resident opened her mouth and said, “Mommy look,” with nothing visible in her mouth. The nurse contacted the police because the aide’s money and keys were not found. In an interview, the Nursing Home Administrator confirmed there was no documentation showing that an investigation was completed to rule out neglect related to the allegation that the resident ingested Zofran after the nurse aide left her pocketbook unattended at the nursing station.
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