Observations
Based on a review of client records and unusual incident documentation, the facility failed to report an incident involving physical assault by a staff or client within 3 business days.
Client #1 was admitted on December 26, 2024 and administratively discharged on January 5, 2025. Discharge documentation indicated that client #1 was administratively discharged due to a physical altercation with another client. There was no documentation that this incident was reported to DDAP within 3 business days, as required.
These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
All managers will be re-educated on DDAP Unusual Incident Alert 01-24 regarding timeframes and categories for unusual incident reporting. The DON will conduct the education.
DON will also educate the ADON on incident reporting guidelines and how to submit incident reports in the DDAP portal. The ADON will be the delegate when the DON is off/unavailable.
The CEO will monitor incident report submissions for the next 3 months to ensure incident reports are entered timely. |