51.3 Notification
(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.
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Observations:
Based on review of facility policy and clinical record, and staff interviews, it was determined that the facility failed to report an allegation of abuse to the Department of Health (DOH) for one of four residents reviewed (Resident R1).
Findings include:
Review of facility policy entitled "Resident Abuse, Neglect or Misappropriation of Property" dated 1/3/24, revealed "The administrator/designee will... file the necessary report to the Department of Health through the electronic reporting system." and "The alleged abuse/neglect/misappropriation will be reported to the authorities per regulation."
Review of Resident R1's clinical record revealed an admission date of 7/19/23, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), diabetes (condition of improper blood sugar control), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).
Review of an incident report for Resident R1 revealed an incident dated 1/12/2024, of being found on the floor with an investigation for an allegation of abuse attached. The investigation revealed a completed investigation with an outcome that abuse was unfounded.
Review of events reported to the DOH by the facility dated from 11/27/23, through 2/26/24, revealed there was no report submitted for the allegation of abuse to the DOH for Resident R1.
During an interview on 2/29/24, at 11:07 a.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to report the allegation of abuse for Resident R1 to the DOH per regulation.
| | Plan of Correction - To be completed: 03/22/2024
This Plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of the Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of correction is submitted to meet requirements established by state and federal law.
Upon notification of any suspected abuse, the Administrator, Director of Nursing, or designee, will immediately report the allegation to the Department of Health, with an internal investigation underway.
On February 29, 2024, all incident reports related to potential abuse dated back to December 6, 2023, were reviewed. None of the incidents reviewed met the criteria for reporting to the Department of Health.
Re-education on the Abuse and Neglect policy, including identifying signs of abuse and proper reporting procedures, will be conducted with all administrative staff.
Weekly audits of all facility incident reports will be conducted by the Administrator or designee going forward. Any event with a suspected allegation of abuse will be immediately reported to the Department of Health.
The results of these audits will be reviewed by the QAPI team Monthly for further recommendations and continued compliance.
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