Failure to Report Resident's Hospital Transfer Due to Soap Ingestion
Penalty
Summary
The facility failed to report an incident involving a resident who was transferred to the hospital after consuming a liquid soap product. The resident, who has medical diagnoses including dementia, heart failure, hypertension, stage 3 kidney disease, anxiety, and major depressive disorder, was found by a Certified Nursing Employee with a soap bottle up to their mouth. The resident was later discovered in their room with large amounts of vomit on the floor and an empty soap bottle in hand. Despite the severity of the situation, the incident was not reported to the Director of Nursing or the Department of Health as required. The incident was initially observed by Certified Nursing Employee E3, who reported it to Licensed Nursing Employee E4. However, the Director of Nursing confirmed that the incident was not communicated to them at the time it occurred. The failure to report the incident in a timely manner is a violation of the requirements under 42 CFR Part 483, Subpart B, and the 28 PA Code, which mandate immediate reporting of such incidents to the appropriate authorities.
Plan Of Correction
1. Resident 2 has suffered no adverse effects and a thorough investigation was complete. 2. Director of Nursing to be re-educated by designee and educate other staff members involved in any investigations the importance of thoroughly investigating allegations. 3. Director of Nursing or designee will conduct weekly audits x 12 weeks to ensure all DOH Event Reports are thoroughly investigated. 4. Nursing Home Administrator or designee will review outcome audits at QAPI Committee X 3 months. 5. March 15th, 2025