Failure to Report Unexpected Resident Death as Required
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not reporting an unexpected resident death to the State Survey Agency (SSA) as required by both facility policy and state and federal regulations. The policy mandates that any allegation or suspicion of abuse, neglect, or unexpected death be reported immediately, no later than two hours from the incident, and that the results of the investigation be submitted within five working days. In this case, the incident log and interviews confirmed that the unexpected death was neither reported to the SSA nor investigated by the facility. The resident involved had been admitted for short-term rehabilitation following a heart procedure and was found dead unexpectedly. The administrator was unaware that the death had not been reported, as the responsibility was delegated to the DON, who stated they did not recognize the death as unexpected and therefore did not report it. A corporate clinical resource confirmed that facility guidelines require reporting such incidents to the SSA, police, and coroner or medical examiner. Despite these requirements, the facility did not fulfill its reporting obligations for this incident.