Failure to Report Unusual Resident Death to State Authorities
Penalty
Summary
The facility failed to timely report an event of unknown source that resulted in a resident’s death to the state Department, as required by regulation and by its own policy on unusual occurrence reporting. A resident was found slumped over in his wheelchair in the lower parking lot, and someone called 911. Paramedics arrived, performed CPR, and then pronounced the resident dead in the facility’s driveway. The Administrator stated that the facility first became aware of the resident’s death only after paramedics had completed CPR, pronounced the resident, and notified the nurses working in the facility. The Administrator further stated that he did not report this resident death to the Department because he did not consider it to be an unusual occurrence and believed he did not have to report it. The Administrator also stated he had not concluded his investigation and did not have interviews with staff who responded to the incident, and therefore did not report the event. In contrast, the Director of Staff Development stated that the resident’s death was an unusual occurrence and should have been reported to the Department. The DON stated that she understood an unusual occurrence to include events such as a fire, flood, or the sudden death of a resident, and confirmed that this resident’s death was definitely an unusual occurrence that should have been reported. The facility’s written policy on Unusual Occurrence Reporting specified that the death of a resident due to unnatural causes (e.g., suicide, homicide, accidents) must be reported to appropriate agencies, with a written report sent within 48 hours of reporting the event, but this process was not followed for this resident’s death in the driveway.
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