Failure to Report Resident Disclosure of Outside Weight Loss Medication
Penalty
Summary
The deficiency involves staff failing to report a resident’s disclosure that he was receiving a weight loss medication from his family that was not provided or ordered by the facility. The resident was an older adult male with acute respiratory failure as his primary diagnosis and additional conditions including anxiety disorder, acute on chronic systolic congestive heart failure, acute pulmonary edema, type 2 diabetes mellitus, and obesity. His medical record showed no physician order for a weight loss medication and no care plan addressing weight loss medication or self-administration of medications; his care plan specified that medications were to be given as ordered by the physician. On one occasion, a nurse (LVN A) documented entering the resident’s room and witnessing a family member handing the resident a syringe, then observing the resident self-inject into his lower abdomen. The family member stated at that time that the injection was for anxiety and claimed that everyone in the facility knew about it. LVN A requested to see the syringe, but the family member refused and later stated it was just water used as a placebo. The nurse documented the event and notified the DON and physician. Another nurse (LVN D) reported that the same family member told staff at the nurse’s station that the medication was for weight loss, and LVN D stated she did not hear the family member say it was for anxiety. A CNA (CNA B) later reported that the resident had told her his family member was giving him medication for weight loss. CNA B stated she never actually saw the family member give the medication and had not heard from other staff that the resident was taking weight loss medication, and she did not report the resident’s statement to her supervisor because she did not think it needed to be reported at the time. Other licensed nursing staff (RN C and LVN D) stated they had not been told by the resident that he was taking medications not provided by the facility and indicated they would have reported such information to the DON, ADM, and physician if they had known. The facility’s abuse/neglect policy states that each individual is responsible for recognizing and reporting situations that may constitute abuse or neglect, and that any person with reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state, and/or adult protective services. Despite this policy and the expectation from the DON and ADM that staff report knowledge of residents receiving outside medications, CNA B did not report the resident’s disclosure about weight loss medication, leading to the cited deficiency.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.