Failure to Identify and Report Neglect After Choking Incident
Penalty
Summary
A resident with a history of stroke resulting in right-sided paralysis, chronic respiratory failure with hypoxia, and dysphagia experienced a choking episode. During this incident, staff failed to provide essential life-saving interventions, such as airway clearance, assessment of lung air movement, and initiation of CPR. Paramedic records indicated that upon arrival, the resident was pulseless and exhibiting agonal respirations, and no life-saving measures had been performed by facility staff prior to their arrival. An LPN present at the scene reported that after being alerted by the resident's spouse, he checked vital signs and increased supplemental oxygen but did not assess lung sounds or initiate further emergency interventions. The facility did not identify or report the incident as an allegation of neglect, as required by their own policies and state regulations. The DON stated during an interview that the incident was not reported to the State because he was unaware of any allegations of inappropriate care. The failure to recognize and report the lack of essential assessment and intervention following the choking event constituted a deficiency in the facility's abuse and neglect reporting procedures.