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 harm. The incident involved a resident who was cognitively intact but required extensive assistance with daily care needs and had a diagnosis of dementia. On a specific date, the resident's spouse attempted to take her from the facility, but she was unable to stand to get into the car. This led to the spouse becoming extremely frustrated with both the resident and the staff. The situation escalated to the point where police presence was required, and the police had to contact crisis services due to a comment made by the spouse. After the situation was de-escalated, the resident remained safe at the facility, and her daughter was informed and agreed that the facility was the safest place for her. However, the Director of Nursing confirmed that the Department of Health was not notified of this incident, which constitutes a failure to meet the regulatory requirement for notification.
Plan Of Correction
Unable to retroactively notify the Department of Health of incident that had the potential for harm to a resident. Residents who receive care and services at the facility have the potential to be affected. Director of Nursing was educated by the Administrator on reporting incidents that have the potential for harm to a resident to the Department of Health. The Director of Nursing will review questionable incidents with the Administrator to ensure compliance in reporting. The Administrator or designee will audit and review incident reports to ensure the necessary reporting is completed. Audits will be conducted as follows: 3.) Up to 5 records will be reviewed daily for 4 weeks. 4.) Then up to 10 records will be reviewed monthly for 2 months. Results of the audits will be provided by the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.