Failure to Timely Report Resident Death and Serious Incident to State Agency
Penalty
Summary
Facility staff failed to timely report an incident of suspected abuse, neglect, or mistreatment, as required by the facility’s Abuse Investigation and Reporting policy, which mandates that alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but not later than two hours. The incident involved a resident with multiple diagnoses, including acute respiratory failure with hypoxia, epilepsy, dysphagia following cerebral infarction, diabetes mellitus, and schizophrenia, who was admitted on a prior date. At approximately 3:00 AM, during a supervisor’s round, the resident was found on the floor in the doorway of the room, lying in a supine position, unresponsive, with the tracheostomy dislodged. A rapid response was called, CPR was initiated by the code team, and EMS (911) arrived and continued ACLS protocols. Despite the seriousness of the event and the resident being pronounced deceased at 3:51 AM after several rounds of CPR, the facility did not report the incident to the State Agency until approximately 7:26 PM the same day, about 16.5 hours after the incident occurred. The Facility Reported Incident documented that the resident was found in the doorway with the trach dislodged and that an investigation was underway, but at the time of the report, facility staff did not disclose that the incident had resulted in serious injury, harm, or death, even though they had knowledge of the resident’s death. During a face-to-face interview, the DON acknowledged the findings and made no comment.
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