Failure to Notify Family of Resident Death Due to Police Directive
Penalty
Summary
Facility staff failed to notify the resident's representative or family of a significant change in condition, specifically the death of a resident, as required by facility policy and regulatory standards. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including a healing cervical fracture, hypertension, and anxiety disorder, died in the facility. Documentation showed that staff performed CPR until EMS arrived, and the time of death was recorded. The incident was complicated by another resident's report of a possible altercation, leading to a police investigation. During the police investigation, facility staff, including the DON, ADON, and Administrator, were instructed by law enforcement not to notify the family of the resident's death, as the scene was considered a crime scene and the police stated it was their responsibility to notify next of kin. Staff complied with this directive and did not inform the family until the family called the facility themselves. At that point, the ADON confirmed the death but could not provide further details, instead directing the family to contact the police investigator for more information. Interviews with facility leadership confirmed that they did not inform the police of their regulatory requirement to notify the family, nor did they seek guidance from the Ombudsman, state program management, or the Medical Director regarding the conflict between law enforcement instructions and facility policy. The facility's own policy required timely notification of family or legal representatives in the event of significant changes in a resident's condition, but this was not followed due to the police directive.