51.3 Notification
(f) If a health care facility is aware of a situation or the occurrence of an event at the facility which could seriously compromise quality assurance or patient safety, the facility shall immediately notify the Department in writing. The notification shall include sufficient detail and information to alert the Department as to the reason for its occurrence and the steps which the health care facility shall take to rectify the situation.
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Observations:
Based on review of facility policy, facility documents, and staff interview, it was determined that the facility failed to notify the State Survey Agency of a significant gastrointestinal outbreak for 22 of 53 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22).
Findings include:
A review of facility policy "Infection Prevention and Control Program", dated 2/15/23, indicated that the facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
A review of facility "Outbreak Case - Patient Line List", indicated the following:
12/27/23 Resident R1 - onset symptoms of Nausea (N), Vomiting (V), and diarrhea (D)
12/28/23 Resident R2, R3, R4, R17, R21 - onset symptoms of N, V, and D Resident R11 - onset symptoms of N and V Resident R5, R12, R13, R14, R15 - onset symptom of D
12/29/23 Resident R6 - onset symptom of V
12/30/23 Resident R9, R16, R18 - onset symptoms of N, V, and D Resident R19 - onset symptoms of D Resident R20 - onset symptoms of N and fever (F)
1/1/24 Resident R7 - onset symptoms of N, V, and D
1/3/24 Resident R22 - onset symptoms of D
1/4/24 Resident R10 - onset symptoms of N, V, and D
During an interview on 1/19/24, at 3:45 p.m., the Nursing Home Administrator confirmed that the facility failed to notify the State Survey Agency of a gastrointestinal outbreak that occurred in the facility between 12/27/23 - 1/4/24.
| | Plan of Correction - To be completed: 02/15/2024
- Reportable ERS being completed to notify of the Norovirus outbreak that occurred
- No other residents were affected by this except the residents identified in the line listing kept during outbreak
- DON and Infection Preventionist will be educated by NHA or designee on proper reporting of health department reportable diseases through the DOH ERS site
- Any further DOH reportable health diseases will be audited to ensure proper reporting is completed. Any findings will be reviewed through facility QAPI process.
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