Failure to Report Incidents to DOH
Penalty
Summary
The facility failed to notify the Pennsylvania Department of Health (DOH) field office of reportable incidents/accidents involving four residents. Resident R9, admitted with a stroke and left-sided paralysis, rolled out of bed and was sent to the emergency room for a hip evaluation. Resident R13, with a history of stroke and Parkinson's Disease, fell while being pushed in a wheelchair, resulting in a hospital admission. Resident R14, diagnosed with prostate and bone cancer, fell and was found unresponsive with a head injury, necessitating emergency department evaluation. Resident R15, suffering from dementia and Alzheimer's Disease, sustained a head injury from a fall in the dining room and was also sent to the emergency room. The facility's documentation and clinical records lacked evidence of these incidents being reported to the DOH field office, as required by regulation 51.3 (g)(1-14). During an interview, the Nursing Home Administrator confirmed the failure to report these incidents. This oversight represents a deficiency in the facility's compliance with state notification requirements, potentially compromising patient safety and quality assurance.
Plan Of Correction
The incidents involving R9, R13, R14, and R15 will be reported to Pennsylvania Department of Health Electronic Reporting system. The Director of Nursing or designee will conduct a look back of past 30 day transfers, and if any transfer is identified as a result of an incident or accident, it will be reported to the Department of Health electronic reporting system. Education was provided to the Director of Nursing and the Nursing Home Administrator on reportable events and criteria for reporting by the Regional Director of Clinical Services. All incidents will be reviewed in the Morning Meeting to determine if they meet the requirements for reporting to the Department of Health. Audits will be conducted to determine if an incident is a Department of Health reportable incident by the Director of Nursing or the Nursing Home Administrator on all incidents for 2 weeks, and then 5 incidents weekly until cleared by Quality Assurance.