Failure to Report and Investigate Possible Neglect After Choking Incident
Penalty
Summary
The facility failed to implement its abuse/neglect reporting policies by not reporting and investigating a possible neglect incident involving one resident. Facility policy dated 3/26/25 required that alleged violations involving abuse/neglect be reported immediately to the Administrator and that results of all investigations be reported to the Administrator and the PA Department of Health within five working days. The resident involved had multiple diagnoses including MS, chronic pain, depression, and anxiety, was alert and oriented, able to understand and be understood, and was dependent on staff for all ADLs, including eating. On the date of the incident, nursing progress notes documented that during dinner the resident began coughing, felt like food was stuck, had difficulty breathing, and was choking and vomiting food. The resident was assessed, the physician was notified, a chest X-ray was ordered, and the following day the X-ray showed minimal right base atelectasis, with Augmentin ordered for pneumonia. During a later interview, the resident reported that a CNA had been feeding her, that her head was too flat while eating, that she said she could not do it, and that she subsequently developed pneumonia. The resident stated that Administration was aware of the incident and had interviewed her the following day. However, the DON acknowledged that no investigation documentation was completed, and the January incident and accident log did not include the choking incident. Documentation submitted by the facility to the State Survey Agency did not include any report of possible neglect related to this event. The Medical Director stated that the choking incident should have been reported per facility policy, and the Nursing Home Administrator confirmed that the facility failed to implement its policies and procedures to report possible neglect for this resident.
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