Failure to Investigate Alleged Neglect and Provide Timely Care
Penalty
Summary
The facility failed to investigate an allegation of neglect and did not ensure staff recognized a change in a resident's condition or provided timely interventions. A resident with severe cognitive impairment, multiple comorbidities including encephalopathy, diabetes, stroke, heart failure, and dementia, and who was dependent on staff for all activities of daily living, was found unresponsive after midnight. Staff initiated CPR and the resident was transferred to the hospital, where EMS and hospital records documented the resident was already in rigor mortis with a core body temperature of 90.7°F, indicating the resident had been deceased for some time before staff intervention. The care plan required repositioning every two hours due to a stage 4 pressure wound, but documentation and staff interviews revealed inconsistencies regarding whether care was provided during the evening shift. Staff interviews and medical record reviews showed that the assigned CNA for the 3 PM to 11 PM shift did not provide care to the resident and documented the resident as not available, despite being assigned to her. Multiple staff accounts conflicted regarding the timing and actions taken during the code blue event, with some staff stating the resident was already deceased and in rigor mortis when found. The facility administration did not conduct a thorough investigation, failing to obtain statements from all involved staff, including the staff member who initially alleged neglect, and did not seek statements from EMS responders. The facility also delayed reporting the incident to the State Agency, submitting the required Immediate and Five Day reports approximately 27 days after becoming aware of the allegation. The Administrator and DON were unable to explain the discrepancies in staff accounts or provide evidence that the resident received timely and appropriate care. They also could not account for the delay in reporting the incident or the lack of a comprehensive investigation, including not interviewing key witnesses or considering the hospital's findings of rigor mortis. There was no evidence that the facility addressed potential neglectful actions prior to or during the code blue event.