(c) The licensee through the administrator shall report as soon as possible, or, at the latest, within 24 hours to the appropriate Division of Nursing Care Facilities field office serious incidents involving residents as set forth in § 51.3 (relating to notification). For purposes of this subpart, references to patients in § 51.3 include references to residents.
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Observations:
Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the Department of Health of an incident that had the potential for serious harm to residents.
Findings include:
An incident investigation, dated March 31, 2024, revealed that according to staff, Nurse Aide 1 came back from his break and was slurring his speech, nodding off, unsteady on his feet, and was unable to recall a resident fall that he reported to the registered nurse.
An interview with the Director of Nursing on May 1, 2024, at 1:30 p.m. revealed that she was called by staff at 2:00 a.m. on the morning of March 31, 2024, to alert her of Nurse Aide 1's behavior. She stated that she informed them to complete a form called reasonable suspicion checklist. Nurse Aide 1 consented to a drug screen, which was completed at the facility and sent to the lab. The Director of Nursing stated that Nurse Aide 1 was sent home after testing, pending the results and investigation. The results of the drug screen on April 2, 2024, revealed that Nurse Aide 1 tested positive for benzodiazepines (a class of drugs that slow down the central nervous system). The facility educated Nurse Aide 1 on the facility's drug-free workplace policy and offered him drug rehabilitation and gave him a final last chance agreement.
A witness statement from Nurse Aide 1, dated April 1, 2024, at 12:14 p.m., confirmed that he took the unprescribed medication while on duty.
An interview with the Director of Nursing on May 1, 2024, at 1:30 p.m. confirmed that the Department of Health was not notified of the incident and should have been.
Chapter 51.3(f) Notification.
| | Plan of Correction - To be completed: 05/21/2024
The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the survey ended on May 1, 2024.
1. Actions taken for the situation identified:
Observations revealed no injuries or ill effects to any resident.
The incident was reported to and accepted by the Department of Health through the Electronic Reporting System on 5/2/2024.
2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected. The reporting requirements have been reviewed by facility managers to ensure timely notifications are made appropriately going forward.
3. System changes and measures to be taken:
To prevent recurrence, when an employee incident occurs, it will be reviewed to determine if there was the potential to compromise resident safety or quality assurance. Incidents that meet the criteria will be reported to the Department of Health through the electronic Event Reporting System as required.
4. Monitoring mechanisms to assure compliance:
To monitor and maintain compliance, the Administrator/designee will be responsible for randomly monitoring employee incident reports monthly for three (3) months to ensure the Department of Health is notified appropriately. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure quality standards continue to be met.
5. Date Corrective Action will be completed:
Substantial compliance is expected by May 21, 2024.
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