Failure to Report and Investigate Possible Neglect Following Resident Aspiration Event
Penalty
Summary
The facility failed to implement its policies and procedures regarding the reporting of possible neglect for one resident. According to the facility's abuse policy, all allegations of neglect must be reported immediately to the Administrator, DON, and the appropriate State Agency. In the case reviewed, a resident with diagnoses including dementia, COPD, and dysphagia had a physician's order to receive medications crushed in pudding or applesauce. However, an LPN provided the resident with whole medications at the resident's request, despite the standing order. The resident subsequently began coughing, experienced respiratory distress, and ultimately ceased to breathe following an aspiration event. Staff attempted emergency interventions, but the resident was pronounced deceased. Documentation and interviews confirmed that whole pills were removed from the resident's mouth during the emergency response. Despite the serious nature of the incident, the facility did not complete an investigation or report the possible neglect to the State Survey Agency as required by policy. Interviews with the DON and Nursing Home Administrator confirmed that no investigation was conducted, and no report was submitted. The failure to follow established procedures for reporting and investigating possible neglect was identified as a deficiency during the survey.