Failure to Thoroughly Investigate Resident Incident Involving Unwitnessed Fall and Choking
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an incident involving a resident who was found unresponsive after an unwitnessed fall in front of the nurse's station. The resident, who had diagnoses including diabetes, depression, and hypertension, was cognitively intact and required supervision with eating and ambulation. The resident was on a pureed diet with thin liquids and had a history of putting foreign objects in their mouth. On the day of the incident, the resident was found lying on the floor, unresponsive but breathing, with a mushy substance coming from their mouth. Staff performed the Heimlich maneuver and initiated a code blue, but the resident was later pronounced deceased after unsuccessful resuscitation efforts. The facility's documentation of the incident was incomplete, lacking statements from all involved staff or potential witnesses and failing to provide evidence of a thorough investigation to rule out abuse, neglect, mistreatment, or care plan violation. The facility's policies required immediate and comprehensive investigation of such incidents, but the investigation did not address possible choking as a factor, despite staff performing the Heimlich maneuver. The Director of Nursing acknowledged that the investigation did not consider choking as a possible cause, and the available reports were insufficiently detailed to determine the circumstances surrounding the incident.