Failure to Notify State Agency of Resident Hospitalization
Penalty
Summary
The facility failed to notify the local State Agency of an incident involving a fall and subsequent hospitalization of a resident, identified as Resident R48. The resident, who had a medical history including Parkinson's disease, anxiety disorder, seizure disorder, and lack of coordination, experienced an incident where he pulled out his G-tube after throwing himself out of his wheelchair. This incident occurred after the resident was unable to be soothed by staff and was taken to the nurse's station for monitoring due to screaming. The resident was then sent to the Emergency Room for re-insertion of the G-tube following the incident. Despite the severity of the incident, which involved a fall and required hospitalization, the facility did not report this event to the local State Agency as required by regulation 51.3 (g)(1-14). The Director of Nursing confirmed during an interview that the notification was not made. This oversight represents a failure to comply with the notification requirements for events that seriously compromise quality assurance and patient safety.
Plan Of Correction
The facility cannot retroactively go back and make corrections. Moving forward, the facility will report allegations of resident-to-resident abuse in the required timeframe. To identify other residents that have the potential to be affected, the DON/designee reviewed progress notes from date of exit (1/16/2025 to current) to ensure those occurrences that meet the requirement are reported timely. Corrections will be made as needed. To prevent this from recurring, the RDCS provided education to the NHA and DON on the regulatory requirements of F609 and timely reporting of resident-to-resident abuse. To monitor and maintain ongoing compliance, the NHA/designee will audit resident events weekly x4 then monthly x 2 to ensure those occurrences that meet the requirement are reported timely. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. The ERS event was submitted-#1070952.