Failure to Report Unexpected Resident Death and Initiate Investigation
Penalty
Summary
The facility failed to report an unexpected death of a resident to the State Survey Agency and did not initiate an internal investigation or document clinical findings in the medical record following the event. The resident, who had diagnoses including end-stage renal disease, chronic respiratory failure with hypoxia, diabetes mellitus, and hypertension, passed away after attending dialysis offsite. Despite the unexpected nature of the death, the facility did not complete an incident report or conduct a mortality investigation. Interviews with facility staff, including the ADON and Administrator, confirmed that no formal review or report was submitted to the State Survey Agency because the death occurred offsite. The Medical Director was notified of the death and stated an expectation that the facility would notify the State Survey Agency in such cases. Review of the resident's progress notes and records showed no evidence of an internal investigation or reporting of the event.