Failure to Investigate Resident Death and Ensure Staff Compliance with Code Protocols
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources, as evidenced by its response to the death of a resident with a Full Code status. The resident, who had multiple complex medical diagnoses including arthritis due to bacteria, severe protein-calorie malnutrition, congestive heart failure, Alzheimer's disease, COPD, hypotension, and diabetes with chronic kidney disease, was found unresponsive by a CNA. The LPN on duty assessed the resident, verified the code status, and initiated CPR for approximately five minutes before stopping. The LPN did not call 911 or initiate a Code Blue, which was contrary to facility protocol for Full Code residents. The LPN also pronounced the resident's death, which was outside the scope of practice for an LPN, and failed to notify the RN on duty or document the incident in a timely manner. The facility's administration did not immediately investigate the death or implement measures to ensure resident safety. There was a significant delay in reporting the incident to the appropriate agencies, with the event being reported five days after it occurred. The investigation was not thorough, as written witness statements were not obtained promptly, and the staff involved were not suspended pending investigation. The decision not to report the incident initially was based on the belief that it did not meet reporting requirements, despite evidence to the contrary. The facility also failed to ensure that all staff were aware of and followed the resident's advance directives and code status protocols. Additionally, the LPN involved in the incident was found to have an ineligible Level II background screening status, with expired fingerprints, yet continued to provide direct care to residents. The Human Resources Manager was unaware of the LPN's ineligible status until after the incident. These failures in administrative oversight and adherence to policy placed other residents with Full Code status at risk of avoidable and untimely deaths, as immediate and appropriate actions were not taken to investigate the event, ensure staff competency, or maintain regulatory compliance.