Failure to Timely Report Suspected Neglect Following Resident Choking Death
Penalty
Summary
The facility failed to report an incident of possible neglect to the State Survey Agency in a timely manner after a resident experienced a fatal choking episode during a meal. The resident, an elderly male with diagnoses including diabetes, vascular dementia, major depressive disorder, and anxiety, was on a mechanically soft diet and required meal assistance as needed. During dinner, the resident began choking, and staff attempted to clear the airway with a finger sweep and abdominal thrusts, but were unsuccessful. The resident's code status was confirmed as Do Not Resuscitate (DNR), and no signs of life were noted after the incident. Despite the severity of the event, the facility did not activate 911 emergency services during the episode. Interviews with facility staff revealed that the incident was not reported to the State Survey Agency because the Director of Nursing (DON) and Administrator believed it was not suspicious and did not constitute neglect, as they were aware of the circumstances and followed internal policy. The DON stated that not calling 911 was not considered neglectful, as it would not have changed the outcome. However, the facility's own policies required reporting all allegations and substantiated occurrences of abuse or neglect, including those resulting in serious bodily injury, to the state agency within specified timeframes. The failure to report the incident as required constituted a deficiency in the facility's abuse and neglect reporting procedures.