Failure to Investigate Resident Death Related to Aspiration
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a severely cognitively impaired resident who was at risk for aspiration and required supervision during meals. The resident, who had a history of wandering and taking other residents' food, was found unresponsive in a hallway late at night. Emergency services were called, and upon their arrival, the resident was found to have food, including peanut butter and meat, lodged in their airway, which required clearing and suctioning before intubation. The resident was pronounced deceased shortly after. Facility policy required that all incidents be documented with a summary of circumstances, including staff and witness statements, and submitted to the Director of Nursing within 24 hours. However, the investigation into this incident was incomplete. Staff interviews revealed inconsistent accounts regarding the presence of food in the resident's mouth and a lack of awareness about the resident's aspiration risk and behaviors. Some staff observed food on the resident's lap and in their mouth, while others denied knowledge of these details. The Director of Nursing collected staff statements but did not conduct a thorough investigation, believing staff had responded appropriately and was unaware of the food found in the resident's airway. The deficiency was cited because the facility did not ensure a comprehensive investigation into the circumstances leading to the resident's death, particularly regarding supervision, aspiration precautions, and the presence of food in the resident's airway. The required documentation and reporting procedures were not fully followed, and the results of the investigation were not adequately reported to the administrator or other officials as required by state law.