Failure to Report Critical Incidents
Penalty
Summary
The facility failed to notify the State Licensing Agency, Department of Health, Division of Nursing Care Facilities, of reportable events involving two residents. Resident 157 sustained a head laceration during a mechanical lift transfer, which required emergency medical evaluation and transfer to a hospital. This incident was documented in the nursing records and a facility investigative report dated August 30, 2024. Additionally, Resident 266 experienced a choking episode that necessitated the Heimlich Maneuver, CPR, and transfer to a hospital, where the resident subsequently expired. This incident was documented in the nurse's notes and a facility investigative report dated January 19, 2025. Upon review, it was confirmed that the facility did not submit these reportable events to the Department of Health, compromising compliance with mandated event reporting requirements.
Plan Of Correction
Step 1- R266 & R157's events were reported. Step 2- To identify other residents that have the potential to be affected, the NHA/Designee will review the last 14 days of incident and accident events to ensure any events that meet the criteria of a state reportable event are reported to the state agency as required. Step 3- To prevent this from reoccurring, re-education was provided by the regional nurse to the NHA/ANHA/DON re: state reportable events. Step 4- To monitor and maintain compliance the NHA/Designee will audit incident and accident reports to ensure any events that meet the criteria of a reportable event to the state is submitted as required. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.