Observations
Based on a review of the facility ' s unusual incident reports from July 2022 to present, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel on three occasions.
An unusual incident report dated August 3, 2022, reported that an ambulance was onsite. There was no documentation this had been reported to the Department.
An unusual incident report dated August 10, 2022, reported that an ambulance was on site. There was no documentation this had been reported to the Department.
An unusual incident report dated September 14, 2022, reported that the police were onsite. There was no documentation this had been reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a reportable incident occurs Lighthouse staff will complete unusual
incident report and submit it to the director of nursing to be reviewed. The nursing director will submit the incident report to DDAP through their unusual occurrence site. The Facility director met with nursing director on 3-15-23 to review incident reporting procedures. On 3-17-23, facility director reviewed incident reporting process with lighthouse staff. The clinical manager will keep a copy of all unusual occurrences that had been reported. |