Failure to Investigate and Report Possible Neglect After Resident Choking Death
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) demonstrated the necessary competencies to recognize, report, and investigate possible neglect following a resident's death. The DON, who was designated as the Abuse Coordinator, did not complete an investigation or report the incident to the State Survey Agency after a resident experienced a fatal choking event. The facility's job description for the DON included responsibilities for reporting any known or suspected allegations of abuse or neglect, but these actions were not carried out in this case. The resident involved had diagnoses of dementia, COPD, and dysphagia, with care plans indicating strict aspiration precautions and a physician's order for medications to be given crushed in pudding or applesauce. Despite this, an LPN provided the resident with whole medications at the resident's request, leading to a choking incident. Staff attempted emergency interventions, but the resident died. Interviews confirmed that whole pills were removed from the resident's mouth during the event, and both the DON and the Nursing Home Administrator acknowledged the failure to recognize, report, and investigate the possible neglect that contributed to the resident's death.