Failure to Thoroughly Investigate Allegation of Neglect Following Resident Death
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident who was found deceased in their room. The resident, admitted with a history of vertebral fractures and orthopedic aftercare, was last reported to have had vital signs taken by a CNA at approximately 6:00 AM. The resident was later found unresponsive, cold to touch, and exhibiting signs of rigor mortis around 7:10 AM, with EMS pronouncing the resident deceased after arrival. There was a discrepancy between the reported time of the last vital signs and the timeline of the resident's death. The facility's investigation into the incident was incomplete. Documentation provided included initial and final incident reports, vital sign flowsheets, nursing progress notes, and statements from some staff. However, the investigation lacked interviews with the resident's roommate, other residents cared for by the accused CNA, and staff from other shifts who had contact with the resident or the accused CNA. The Administrator and ADON confirmed that not all relevant staff or residents were interviewed, and the facility's own policy requiring comprehensive interviews and documentation during investigations was not followed.