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 upon review of facility policy, and staff interviews, it was determined that the facility failed to report an incident to the Department of Health (DOH) in a timely manner.
Findings include:
Review of facility policy entitled "Fire Watch" dated 3/20/2023, revealed that "Our local fire department and state licensing agency shall be immediately notified when there is an unforeseen disablement ... of our fire detection ..."
Review of information submitted by the facility dated 12/20/23, for disruption of the wander guard system (alarming system to alert staff if a resident was exiting the building unattended) not working properly starting on 12/14/23, revealed the information submitted was six days after the incident occurred.
During an interview on 12/27/23, at 11:25 a.m. the Maintenance Director revealed that it was the fire alarming system that was not functioning from 12/14/23, through 12/22/23.
During an interview on 12/27/23, at 11:40 a.m. the Director of Nursing revealed that on 12/14/23, staff placed tabs monitors on the doors that remained unlocked due to the fire system not functioning which would alarm to notify staff if the door was opened.
During an interview on 12/27/23, at 11:58 a.m. the Nursing Home Administrator revealed that it was the fire system not functioning properly not the wander guard system from 12/14/23, through 12/22/23. He/she also confirmed on 12/27/23, at 11:58 a.m. that the Department of Health (DOH) was not notified of the incident in a timely manner.
28 Pa. Code 201.14(a) Responsibility of licensee
| | Plan of Correction - To be completed: 02/05/2024
1. Administrator reported as soon as he/she was made aware that this was a fire alarming system issue and reported through the ERS system on 12/20/2023. CertaSite repair service was immediately called for repairs. "Fire Watch" policy was implemented on 12/14/2023 and continued until fire alarm system was fixed and doors were secured on 12/22/2023. There was no harm to any residents.
2. The Administrator will correct the deficiency by educating all pertinent staff on policy of WHAT IS REPORTABLE, how it is reported, why it is reported, when it should be reported and whom should be reporting through the ERS system to avoid further occurrences. 3. Will review 3 months back of all facility events and incidents to ensure requirements of reporting were met. Will review and discuss ongoing at morning meetings with management staff all facility events and incidents to ensure we are not missing any reporting requirements for further occurrences and to sustain compliance.
4. Findings will be reported to QA committee for further review and monitoring.
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