Failure to Thoroughly Investigate Unexpected Death and Potential Abuse/Neglect
Penalty
Summary
The facility failed to thoroughly investigate a potential abuse/neglect allegation related to an unexpected death for one resident. Facility policy required thorough investigations of potential, suspected, and alleged abuse or neglect, including identifying and interviewing individuals with knowledge of the event and maintaining complete documentation. Resident 2 was admitted with diagnoses including a bladder tumor, kidney disease, and vasovagal response and was receiving skilled services with a plan to return home. An incident report documented that the resident experienced a fall without fracture and an unanticipated death at the same time, 5:30 AM. The incident report included a nursing description, three staff witness statement forms, a visitor’s written statement, and a fall investigation checklist. However, the incident report documented that the fall and unanticipated death were not witnessed, which contradicted statements within the investigation. The investigation also contained a statement attributed to staff, without an associated signed statement, indicating that police and 911 were called after the resident was found on the floor, moved to bed, given oxygen, and then stopped breathing, at which point the crash cart was obtained to start CPR. The incident report did not include a timeline of events, did not identify who performed CPR, did not state how long CPR was performed, and did not list the names of staff involved. The DON stated that for an unexpected death they would expect an investigation to include staff witness statements, past medical history, and a thorough review of diagnoses, and acknowledged that the state hotline was not notified because the death was not considered suspicious. The DON further stated they were unaware that police had been notified and that the police report was not reviewed as part of the investigation. When asked how abuse or neglect was ruled out, the DON stated the resident was very ill and therefore the death was not unexpected, and also indicated that staff were interviewed but that this information existed only as scribbled notes and in their memory, not in the investigation record.
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