Failure to Report Unwitnessed Incident
Penalty
Summary
The facility failed to report an alleged violation involving a resident's unwitnessed incident to the New York State Department of Health within the required timeframe. Resident #230, who had severe cognitive impairment and a diagnosis of dementia, was found sitting on a gym mat next to their bed at approximately 4:00 AM. Despite the resident's inability to explain the occurrence and the subsequent discovery of a right pelvic fracture, the incident was not reported as required by the facility's policy and state regulations. Interviews and record reviews revealed that the nursing staff did not consider the incident a fall because the resident was found sitting on a gym mat. The Director of Nursing acknowledged that the incident should have been reported due to its unwitnessed nature, but it was not reported because they concluded there was no unknown factor or abuse involved. This oversight led to a deficiency in the facility's compliance with reporting requirements for incidents involving potential abuse, neglect, or mistreatment.
Plan Of Correction
Plan of Correction: Approved April 25, 2025 P(NAME): F609 I. Immediate Corrective Actions: Resident # 230 1) On readmission 05/21/2024 the resident was reassessed by the physician and total plan of care was reviewed. 2) On 6/11/24 the IDT Team reviewed and revised the resident plan of care including Falls risk and interventions, family agreeable with plan of care. 3) The RNS reviewed and updated the CNAAR to include any new interventions. II. Identification of Others: 1) The facility states that all residents were potentially affected. 2) All incidents and accidents for the preceding 30 days were reviewed to ensure that any incidents involving injuries of unknown origin, alleged, or actual abuse were reported to NYSDOH. No other issues were identified. III. Systemic Changes: 1) The Policy and Procedure for Abuse Prevention was reviewed by the Administrator in conjunction with the Director of Nursing (DON) and Medical Director and is in compliance. 2) Inservice education will be provided by the Inservice Coordinator for all Direct Care staff including Licensed nurses, CNAs, Social Workers, and IDT Team members on the reporting requirements related to reporting violations involving injuries of unknown origin and actual or alleged abuse to the NYSDOH. 3) Highlights of the Lesson Plan include: - The facility staff must report all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property, immediately to the Administrator/ DON. - Upon notification the DON/Administrator must report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYS DOH. - As per CMS 42CRF 483.12(c) the reporting definition “immediately” is defined as: 1. 2 hours if the alleged violation involves abuse or results in serious bodily injury. 2. 24 hours if the alleged violation does not involve abuse and does not result in serious injury. - As per Federal regulation 483.12(b)(5) all reasonable suspicions of crimes and/or suspicious incidents resulting in serious bodily injury must be reported to the local law enforcement within two hours. - Any reasonable suspicion of a crime not resulting in serious injury must be reported to law enforcement within 24 hours. - The Facility procedure for Staff to notify Administrator/DON immediately of any incidents involving alleged abuse or serious injuries immediately 24hrs day/7 days weekly and the responsibility of the DON or Administrator/ designee to report to NYS DOH to comply with reporting requirements. IV. Quality Assurance: 1) An audit tool was developed to monitor the facility’s compliance with ensuring that all incidents and accidents are investigated, and any injuries of unknown origin or abuse are reported timely as per NYS DOH and Federal reporting guidelines. 2) All Accident and Incidents will be audited by DON weekly x 6 months. Any identified issues will be immediately addressed and shared at morning report. 3) Findings will be reviewed at Monthly QA Meeting to monitor sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025 - Administrator