Failure to Timely Report Investigation Results to State Agency
Penalty
Summary
The facility failed to submit the results of its investigation regarding an incident involving two residents to the New Jersey Department of Health (NJDOH) within the required timeframe. The incident, which involved an event between two residents, was reported to facility administration, and body assessments were conducted. However, the Facility Reportable Event (FRE) was not sent to the NJDOH until several days after the event, as confirmed by staff interviews. The delay was attributed to the facility being engaged in a Directed Plan of Correction (DPOC) at the time. Additionally, the facility did not provide documentation to the surveyor that the investigation was submitted electronically to the NJDOH as required. A review of the facility's undated "Abuse Policy" indicated that a follow-up investigation should be submitted to the State Agency within five working days, including evidence that all alleged violations are thoroughly investigated. The facility's failure to adhere to both federal regulations and its own policy resulted in the deficiency.
Plan Of Correction
Plan of Correction Root Cause: Upon review of the F609 tag, the facility noted the root cause of this issue to be because the facility failed to submit the electronic notification of a reportable event to the DOH within 24 hours of the time of the event. F609 Corrective Action: On 4/25/2025, the Administrator coordinated with the Director of Nursing and Regional Clinical Service Director a review of all reportable events to date to ensure timely submission of all reportable events. On 4/25/2025, the Regional Clinical Services Director conducted an in-service with the Administrator and Director of Nursing on the facility policy and procedure for the submission, with emphasis on facility procedure for timely reporting of all reportable events via DOH electronic reporting site within 2 hours of any allegation of abuse or serious bodily injury and within 24 hours of any allegation not involving injury or abuse incident. Identification of Others: An assessment of the risk this deficient practice could have on residents at this facility was completed by the Administrator, Director of Nursing, and it was found that all residents are at risk of this practice. Systemic Change: The Facility Administrator and Director of Nursing initiated education for all staff within the facility on the facility policy for the reporting of any alleged violations. The Administrator/Designee will review all facility reportable events to ensure timely reporting of all reportable events via DOH electronic reporting site within 2 hours of any allegation of abuse or serious bodily injury and within 24 hours of any allegation not involving injury or abuse incident. This review will be maintained weekly for 1 month and then monthly for the next 3 months. Quality Assurance: The Administrator will submit the findings from the monthly reportable events audit to the QA/QAPI committee. If further actions are deemed necessary, the team will address them. The QA/QAPI committee will meet monthly for the next 3 months to review all findings and assess whether further action is necessary.