Failure to Report Fire Hazard Incident
Penalty
Summary
The facility failed to notify the Department of Health of a reportable event, as required by regulation 51.3 (g)(1-14). The incident involved a potential fire hazard in a resident's room, where a nurse aide detected a 'burning plastic' smell. Upon investigation, staff could not initially locate the source of the smell, but the room began to fill with haze and smoke. The resident and their roommate were promptly evacuated to another room, and the fire department was called to the scene. The fire department identified the source of the smell as the roommate's overhead light, which was burning and melting plastic. Despite the potential risk to patient safety and the significant disruption of services, the Nursing Home Administrator did not report the incident to the Department of Health. During an interview, the administrator stated that they did not believe the incident needed to be reported. This oversight constitutes a failure to comply with the notification requirements for events that seriously compromise quality assurance and patient safety.
Plan Of Correction
Reportable event was completed on 3.11.2025. Moving forward, the facility will report follow the state requirement for reporting events. To prevent this from recurring, the RDCS educated the NHA/DON on the licensure requirements for notification (0009). To monitor and maintain ongoing compliance, the DON/designee will audit facility events/progress notes weekly x4 then monthly x 2. 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.