Failure to Ensure Ethical Practices and Accurate Reporting in Resident Death
Penalty
Summary
The facility failed to ensure staff adhered to ethical practices and professional standards, resulting in inconsistent and misleading statements regarding the circumstances of a resident's death. Staff provided conflicting accounts about the last time the resident was observed, the care provided, and the initiation of CPR. Documentation in the resident's medical record did not align with staff witness statements, and there were discrepancies in the reported times and actions taken during the code event. For example, one LPN documented that the resident was alert and oriented at a time when she later stated she had not assessed the resident, and a CNA's documentation conflicted with her statements about providing care. Further, high-level personnel oversight was lacking, as evidenced by the failure of the DON and Administrator to ensure accurate and truthful reporting. Staff reported being instructed to provide false witness statements under threat of job loss, and there was evidence that the crash cart was placed in the resident's room prior to EMS arrival to give the impression that CPR was in progress. The DON and Administrator denied knowledge of the resident being deceased prior to CPR and failed to report allegations of neglect and ethical violations when they were brought to their attention by staff. The facility also failed to develop effective lines of communication to encourage immediate reporting of violations without fear of retaliation. When a staff member reported allegations of neglect and unethical behavior, these concerns were not reported to the appropriate authorities. The compliance officer confirmed that ethical behavior was expected, but the facility's actions did not support an environment where staff could report violations without fear. These failures contributed to an inadequate investigation into the resident's death and undermined the facility's compliance and ethics program.