Discrepancies About Death of a Resident in Arizona Assisted Living Center Prompt Re-Examination by DOH
An 89-year-old resident was found unresponsive on the floor of a facility’s dining room with a large gash in her head. The staff called 911 and allegedly did nothing further for the resident—they just “stood by and waited” for the EMTs to arrive. The resident was transported to the hospital, but died later that night. A scan performed at the hospital indicated that along with the gash, there were two fractured bones in the resident’s neck.
A nurse reported that he was asked by the interim administrator to lie and say staff had acted appropriately and performed CPR. The nurse claims that because he refused to lie, the facility terminated him within two weeks, citing other patient issues.
Exactly what happened is a mystery. Staff told the family that the resident fell and hit her head on a nearby piano, but the firefighter captain reported there was “no obvious indication the patient struck her head on the piano, and there was no evidence of a blood trail near the patient to indicate movement.”
The Medical Examiner’s Office declined to perform an autopsy and classified the resident’s death as an accident.
Because the police were not notified by the facility, the resident’s family reported the event to them four days after the incident and asked them to investigate. But by then, the scene had been cleaned up by facility. The police investigation found discrepancies in statements from staff about what happened. They determined from the 911 call and reports from the EMTs that CPR had not been performed as the interim administrator had claimed.
Prompted by their own recent reports of “unreported and widespread” abuse in long-term care facilities, the Arizona Department of Health (DOH) is investigating this death and the deaths of several other residents occurring this year in this same facility.
Compliance Perspective
Failing to perform CPR for residents found unresponsive and who are not designated “DNR” and then attempting to coerce employees into lying about staff members’ response, failing to investigate and report an incident to the proper authorities, and failing to promptly notify police about an incident resulting in the death of a resident may be considered abuse and neglect, immediate jeopardy, and provision of sub-standard quality of care in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding the response of staff members when confronted with residents’ emergency response situations, e.g. CPR, calling 911, and notifying local police about injuries with unknown causes or death.
- Train staff about policies and procedures for responding to residents in emergency situations and their responsibility to report any attempted cover-up of mistakes or errors to their supervisor or through the Hotline.
- Periodically audit to ensure that staff respond to emergency situations according to the facility’s policies and procedures.
