Failure to Timely Report Resident Death with Possible Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving a resident who was found deceased with a possible head injury in the visitor bathroom. The resident, an elderly female with a history of cerebral infarction, severe mental impairment (BIMS of 04), diabetes, lack of coordination, history of falling, and unsteady gait, was known to ambulate independently with a walker and frequently used the public restroom. On the morning of the incident, staff noticed the resident was not in her room or the dining area and began searching for her. She was eventually found unresponsive, sitting on the floor of the public restroom with her head bent down, a hematoma on her forehead, and evidence of incontinence and possible trauma. Multiple staff interviews confirmed that the resident was last seen in her room early in the morning and was later discovered in the locked public restroom after staff realized she was missing during routine medication and care rounds. Upon discovery, the resident was unresponsive, had no pulse, and was not breathing. The DON initiated CPR, and emergency responders were called, but the resident was pronounced deceased at the scene. The incident report and nurse notes documented the circumstances and physical findings, including the head injury and the resident's position on the floor. Despite the presence of a possible injury of unknown origin and the resident's death, the facility did not report the incident to the State Agency as required by regulation. The Administrator, who also served as the Abuse Coordinator, stated that the incident was not reported because it was not considered a suspicious death according to her interpretation of state guidelines and facility policy. The facility's policy required reporting of suspicious serious bodily injuries of unknown origin immediately or within two hours, and other incidents within 24 hours, but this incident was not reported as such.