Failure to Secure Staff Belongings and Timely Report Change in Condition Resulting in Resident Death
Penalty
Summary
The facility failed to ensure that staff belongings, specifically prescription medication, were properly secured and inaccessible to residents. A resident with a history of drug use and drug-seeking behavior, residing on a secured behavior unit, was able to access a CNA's unsecured purse left at the nursing station. The resident obtained and ingested up to 20 tablets of Adipex, a stimulant medication, without staff knowledge. The purse was left in an area that was not secured, and the CNA did not have access to a designated secure area for personal belongings on the unit. Following the ingestion, the resident began to display significant changes in condition, including confusion, inability to stand or walk, rapid pulse, and hypertension. These changes were first noted at 7:40 A.M., but the response from nursing staff was delayed. The resident was not transferred to the emergency room until several hours later, despite ongoing and worsening symptoms such as shortness of breath, decreased oxygen saturation, and further decline in mobility and mental status. Documentation of the resident's condition and the actions taken was also delayed, with several progress notes entered as late entries. The resident was eventually transported to the hospital, where she required CPR and intubation and was found to have amphetamines in her system. She was admitted to the ICU with pneumonia and subsequently died after being transitioned to palliative care. The facility's failure to secure staff belongings and to promptly recognize and report the resident's change in condition resulted in resident neglect and actual harm, including the resident's death.