Failure to Timely Report Fire Incident and Resident Death to Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the administrator and appropriate authorities as required. Specifically, the administrator did not report a fire incident in the 400 Hall, which resulted in the exposure of 22 residents to smoke and the death of one resident, to the State Survey Agency within the mandated two-hour timeframe. The incident was instead reported several hours later via email, despite the administrator being informed of the fire and fatality shortly after the event occurred. This delay in reporting was confirmed through record review of the facility's reporting system and interviews with staff. The fire occurred in a resident room and was discovered by a CNA, who observed a resident on fire. Staff responded by extinguishing the fire, contacting 911, and relocating residents from the affected area. Security footage showed staff attempting to evacuate residents, with some delays caused by locked doors and confusion during the evacuation process. The fire department and EMTs arrived on the scene, and one resident was pronounced deceased. The deceased resident had significant medical needs, including total dependence for mobility and ADLs, a history of stroke with left-sided weakness, and was a known smoker who was compliant with the facility's smoking policy. The cause of the fire remained undetermined at the time of the report. Interviews and documentation revealed that after the fire, the resident who suffered fatal burns did not receive an immediate assessment or medical intervention from nursing staff prior to the arrival of EMS. The DON acknowledged that staff were not trained on how to respond to severe burns prior to the incident and confirmed that no assessment was performed on the resident after the fire was extinguished. The medical examiner later confirmed that the resident had been breathing while on fire, with 26% of her body surface burned. Other residents in the affected hall had significant cognitive and physical impairments, requiring various levels of assistance for mobility and ADLs, and were also exposed to smoke during the incident.