Observations
Based on a review of administrative documentation, the facility failed to inform the Department of unusual incidents, involving physical assault, within the required three days.
There were physical altercations between clients on August 30, 2025, and on September 30, 2025.
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Plan of Correction
The facility will ensure that a written unusual incident report will be filed with the Department within 3 days following an unusual incident.
The Nurse Manager will review all Incident Reports to identify any physical altercations and ensure that unusual incident reports are filed with the Department within 3 days of the occurrence of an unusual incident.
Ongoing: The Nurse Manager will conduct quarterly audits of the Incident Report logs to ensure that unusual incident reports were filed with the Department within 3 days of any unusual incident. |