Failure to Investigate Unexpected Resident Death per Abuse Policy
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not conducting a complete and thorough investigation into the unexpected death of a resident who was admitted for short-term rehabilitation following a heart procedure. The resident, who had a goal of returning home, was found deceased unexpectedly, and the facility did not complete an incident investigation as required by their policy. The policy mandates that all allegations of abuse, neglect, or unexpected incidents be promptly and thoroughly investigated, including interviews with relevant parties and a review of medical records, with documentation of the findings. Despite the policy requirements, the facility only provided a one-page, undated timeline of events and did not document staff interviews or a comprehensive review of the circumstances surrounding the death. The Administrator was unaware that an investigation had not been conducted, and the DON stated they did not realize the death was considered unexpected and therefore did not initiate an investigation. The lack of a documented and thorough investigation into the resident's unexpected death constituted a failure to follow the facility's abuse prevention and reporting protocols.