Failure to Notify Department of Health of Incident
Penalty
Summary
The facility failed to notify the Department of Health about an incident involving a resident, which had the potential for serious harm. The resident, who was cognitively impaired and had a history of stroke, was found on the floor beside their bed. Following this incident, neurological checks were initiated. Later, the resident's daughter requested that the resident be sent to the emergency room for evaluation, and the resident was subsequently admitted to the hospital with a diagnosis of a stroke. Despite these events, there was no documented evidence that the incident was reported to the Department of Health until after Adult Protective Services contacted the facility, confirming the delay in notification.
Plan Of Correction
Resident 1 has had an incident reported to the Department of Health. A review of the last 30 days incidents were audited to find any resident who were sent for treatment to verify they had been reported to the Department of Health. Education provided to Director of Nursing regarding the process to report resident admissions to the hospital when they are due to an incident that occurred in the facility. Nursing Home Administrator or designee will audit 3 random resident incident reports for transfer to hospital x 4 weeks, then 3 random records monthly for documentation of Event Report submitted to the Department of Health when appropriate. These audits will be forwarded to Quality Assurance for review.