Failure to Timely Investigate and Report Unexpected Resident Death
Penalty
Summary
The facility failed to ensure that an incident involving the unexpected death of a resident was investigated and reported in a timely manner. According to the facility's policy and the Washington State Guidelines Purple Book, an immediate investigation and prompt logging of such incidents are required. However, review of records showed that the resident's unexpected death was not logged on the incident reporting log until 19 days after the event, and the investigation was not initiated promptly. The online incident report was completed six days after the resident's death, and the incident was not included in the April incident log, only appearing in the May log after a significant delay. Interviews with facility staff, including the Director of Health Services and the Interim DON, confirmed that the incident was neither investigated nor reported in accordance with required timelines. Staff acknowledged that the reporting and investigation were not completed in a timely manner, and the incident was logged late. These actions were not consistent with both facility policy and state guidelines, which require immediate response and documentation for unexpected deaths, especially those that are suspicious or not clearly related to abuse or neglect.