F0609

D

Failure to Report Allegation of Neglect After Repeated Chest Pain Complaints and Resident Death

Lakewood, Ohio Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of neglect to the State agency after a resident experienced repeated complaints of chest pain prior to death. The resident had diagnoses including acute on chronic congestive heart failure, atrial fibrillation, atherosclerotic coronary heart disease, hypertensive heart disease with heart failure, muscle weakness, and ischemic cardiomyopathy. On admission assessment, the resident’s memory was intact, he had modified independence for daily decision-making, required supervision with eating, was dependent for toileting hygiene, and needed partial/moderate assistance with bed mobility and transfers. The resident had a PRN order for aluminum and magnesium hydroxide suspension for antacid but no PRN orders for chest pain.

On the night in question, the electronic MAR showed that an RN administered PRN Maalox around 12:28 A.M. and later documented at 4:21 A.M. that the medication was effective. However, there was no documented assessment or vital signs around the time of Maalox administration in the medical record. A health status note at 5:13 A.M. documented that the resident was found in bed without vital signs, 911 was called, CPR was initiated, and EMS and police arrived. The EMS run report indicated EMS was dispatched shortly after 5:14 A.M. and arrived to find the resident unresponsive, not breathing, pulseless, with rigor mortis and mottling present, and asystole confirmed in multiple leads; a physician pronounced death at 5:28 A.M. A device activity report showed the resident activated the call light multiple times between approximately 11:07 P.M. and 12:48 A.M.

Interviews with staff revealed that multiple CNAs reported the resident’s complaints of chest pain or chest tightness to the RN. One CNA stated the resident repeatedly complained of chest pain and appeared in distress, and that she informed the RN twice, while other CNAs also reported chest tightness or chest pain to the RN. CNAs described the resident as frequently using the call light and verbally expressing chest discomfort, with one CNA stating the resident looked like he was in distress and had his hand on his chest. The RN reported that the resident described indigestion, that she administered Maalox, took and retook blood pressure (which she did not document), and later observed the resident sleeping. The facility’s abuse/neglect policy required that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation, and injuries of unknown source be reported immediately to the Administrator or designee and to the State agency within 24 hours. The Administrator and DON both acknowledged that a CNA reported concerns that the nurse did not act on the resident’s complaints, but they did not report this allegation to the State agency, leading to the cited failure to report an allegation of neglect.

The Administrator stated that she was aware of the CNA’s account that the resident had complained of chest discomfort and that the nurse did not seem concerned or take action, and that the CNA was telling others that the nurse did nothing regarding the complaints. The Administrator explained that she did not report the matter to the State agency because she perceived the CNA’s statements as characterizing the nurse as lazy rather than as a true concern. The DON similarly stated that the CNA came to her the very next day and reported that the nurse did not do anything regarding the resident’s complaints of pressure and discomfort, but the DON also did not report this to the State agency. Despite the facility’s written policy requiring immediate reporting of allegations of neglect to the Administrator and to the State agency within 24 hours, there was no evidence that this allegation was reported, constituting the deficiency.