Failure to Investigate Resident Fall and Unexpected Death
Penalty
Summary
The facility failed to complete and thoroughly investigate a fall incident involving a cognitively impaired resident who was found unresponsive on the floor next to their bed with their head in a trash bin lined with a clear plastic bag. The resident, who had a history of epilepsy, developmental disorder, osteoarthritis, muscle weakness, and difficulty walking, was assessed as having severely impaired cognition and required staff assistance for activities of daily living. The incident occurred when a CNA, after hearing a noise, found the resident unresponsive and immediately notified nursing staff, who initiated emergency response procedures. EMS and police arrived, and the resident was pronounced dead at the scene. Despite the seriousness of the event, the facility did not submit a required Investigation, Summary, and Conclusion (ISC) to the state health department, nor did it provide complete investigation documentation, including staff statements. The only available statements were those taken by local police. The facility's own investigation summary lacked thorough documentation and did not include evidence of a comprehensive internal investigation as required by facility policy. The absence of a complete and documented investigation into the incident constituted a failure to rule out abuse and neglect, as mandated by regulatory guidelines.