Failure to Timely Recognize and Report Allegations of Abuse, Neglect, and Unexpected Death
Penalty
Summary
The facility failed to ensure timely recognition and reporting of allegations of abuse, neglect, or unexpected death for two residents. For one resident, who was admitted with a left femur fracture, malnutrition, and dysphagia, staff found the individual unresponsive and not breathing, with no prior hospice or end-of-life care in place. Despite this being considered an unexpected death by staff, the incident was not coded or reported as such in the facility's state reporting log, nor was it investigated or reported to the appropriate authorities as required by state guidelines. Interviews revealed that key staff, including the ADNS and Administrator, were unaware of the requirement to log and report unexpected deaths for residents not on hospice or end-of-life care. For another resident with sarcopenia, chronic pain syndrome, dementia, and legal blindness, staff reported that the resident's call light was found out of reach on multiple occasions during night shifts. Although a nursing assistant reported the issue to supervisory staff, there was uncertainty about whether the potential intentional nature of the act was communicated. Supervisory staff and the Administrator were unaware that the incident could have constituted intentional neglect and did not report it as such. The facility's failure to recognize and report these incidents in accordance with abuse and neglect reporting policies resulted in a deficiency.