Observations:
Based on clinical record review and staff interviews, it was determined that the facility failed to report each resident's transfer to the hospital as the result of an accident to the State Agency as required for two of six sampled residents (Resident R1 and R2).
Findings include:
A review of the clinical record indicated that Resident R1 was transferred to the hospital on February 6, 2026. Nursing documentation on that date indicated that the resident experienced a fall with a resulting forehead laceration and elbow skin tear. A physician ordered that the resident be sent to the hospital emergency room.
A review of the clinical record indicated that Resident R2 was transferred to the hospital on February 28, 2026. Nursing documentation on that date indicated that the resident experienced a fall with a resulting hematoma to the head. A physician ordered that the resident be sent to the hospital emergency room.
There was no evidence to support that the resident's transfer to the hospital as the result of an injury or accident had been reported to the State Agency as required.
During an interview on March 4, 2026, at 2:45 p.m., the Nursing Home Administrator and Director of Nursing confirmed that Resident's R1 and R2's transfer to the hospital had not been reported as required.
| | Plan of Correction - To be completed: 03/30/2026
Regarding Resident R1 and Resident R2, the facility submitted the required retroactive notifications to the Department on March 4, 2026. To ensure no other residents were affected, the Director of Nursing (DON) completed a full audit on March 4, 2026, of all hospital transfers resulting from accidents over the previous 30 days; any identified reporting gaps were immediately corrected. To prevent a recurrence, the Nursing Home Administrator and Director of Nursing were re-educated on March 4, 2026 by the Regional Director of Clinical Services with PACS, regarding the specific mandates of PA 51.3(f) and the requirement to notify the Department in writing immediately when a resident is transferred to the hospital due to an accident or injury. To monitor for ongoing compliance, the DON or a designee will audit all hospital transfers weekly for a period of three weeks to ensure that all required notifications have been sent. The findings of these audits will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for review and to determine if further monitoring is required. The facility expects to be in full compliance by March 30, 2026.
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