Failure to Investigate and Review Adverse Event Resulting in Resident Death
Penalty
Summary
The facility failed to identify and investigate an adverse event involving a resident who was found unresponsive with her chin and neck pressed against the bed frame, her lower body on the floor, and required CPR according to her code status. The resident had a history of Parkinson's disease, seizure disorder or epilepsy, difficulty walking, and moderately impaired cognition. Staff interviews revealed that the resident was discovered in a face-down, back-bending position, and was unresponsive with no pulse or breathing detected. Despite the circumstances, no incident report was created for this event, and there was no evidence of a Quality Assurance and Performance Improvement (QAPI) review or internal investigation by the facility's Quality Assessment and Assurance (QAA) committee. The facility's policies required the QAA committee to oversee the identification and handling of quality issues, including adverse events and negative outcomes related to resident care and safety. However, the committee did not identify the resident's death as an adverse event, did not initiate an incident report, and did not review or investigate the incident. The Regional Support Administrator acknowledged that a death from an injury of unknown origin should be considered an adverse event and reviewed by the QAA committee, but confirmed that this did not occur in this case.