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.
|
Observations:
Based on observations and staff interviews, it was determined that the facility failed to report a disruption in service to the Department of Health.
Findings include:
Observations on July 18, 2024, at 10:12 a.m. with Director of Maintenance, Employee E3 revealed that the main air conditioning system, responsible for cooling hallways and three nursing units has been out of service since of July 15, 2024.
Despite this, residents' rooms, equipped with window units, maintained temperatures within regulatory limits in their bedrooms.
Interview with the Director of Maintenance, Employee E3 on July 18, 2024, at 12:05 p.m. revealed that the facility identified the issue on July 15, 2024, and rented 6 large air conditioning units to cool down the temperatures in hallways and nursing units.
There was no documentation to indicate that the facility notified Department of Health of interruption of main air conditioning unit service.
Interview with the Nursing Home Administrator, Employee E1 on July 18, 2024, at 1:44 p.m. confirmed that the Department of Health was not notified of the air conditioning system being out of service.
Chapter 51.3(f) Notification.
| | Plan of Correction - To be completed: 08/01/2024
Reportable has since been reported to DOH.
NHA/DON will be educated on reporting events appropriately to DOH.
Designee will audit Weekly X4, then monthly X2 to ensure that reportables are being submitted appropriately.
Results will be discussed in QAPI and determined if further auditing is necessary.
|
|
