Failure to Investigate and Document Resident Accident per Facility Policy
Penalty
Summary
A deficiency was identified when the facility failed to conduct a thorough investigation and follow its own policy regarding incident and accident reporting after an event involving a resident. The resident, who had multiple medical diagnoses and required assistance with activities of daily living, was involved in an incident outside the facility premises. The resident had signed out of the facility and, upon returning, remained outside the entrance while an accompanying individual went inside to speak with staff. During this time, the resident experienced an incident that required medical attention and was subsequently transported to the hospital by ambulance. The facility's documentation and staff interviews revealed that the required procedures for investigating and reporting the incident were not fully followed. The facility's policy mandates that the licensed nurse who first witnesses an incident must complete an incident/accident report in its entirety, with input from staff present at the time. Additionally, all employees assigned to the resident are required to fill out employee statement forms, and the unit manager is responsible for investigating, summarizing, and concluding all incidents. In this case, the facility did not complete all necessary documentation, including employee statements and a comprehensive summary or conclusion of the incident. Interviews with staff indicated confusion regarding responsibility for follow-up and documentation. One nurse stated that she would have completed the necessary follow-up if the incident had occurred during her shift, but was told by another staff member that they would handle it. The facility administrator confirmed that the policy would have been followed if the incident had occurred on the premises, but no additional documentation or summary was available for the incident. This lack of thorough investigation and incomplete documentation constituted a failure to meet the regulatory requirements for accident investigation and reporting.
Plan Of Correction
1. How the corrective action will be accomplished for those residents found to be affected by this practice? [R] Resident #2. The Regional Nurse alongside the Director of Nursing conducted a new thorough investigation into the incident regarding Resident #2, following the facility policy carefully. The Director of Nursing reviewed the incident report, re-interviewed the resident, as well as staff involved. The Director of Nursing reviewed the Police report as a part of her investigation. After review of those items, it was concluded by the Regional Nurse and the Director of Nursing that the outcome of the re-investigation was the same as the initial investigation. The interventions put in place remained and staff continued to monitor. There were NJ Ex Order 26.4(b)(1) on Resident #2 by the facility's failure to thoroughly investigate and follow the facility policy on investigating incidents and accidents. 2. How the Facility will identify other residents having the potential to be affected by the same deficient practice? (a) All residents have the potential to be affected by the facility's failure to thoroughly investigate and follow the facility's policy on investigating incidents and accidents. 3. What measures will be put in place or what systemic changes will be made to ensure that the deficient practice will not recur? (a) The U.S. FOIA (b) (6) was re-inserviced by the Regional Nurse on the Facility's policy for investigating incidents and accidents. (b) All Nurses were re-inserviced by the Director of Nursing on the facility's policy for investigating incidents and accidents. (c) The Director of Nursing or designee will audit all incidents and accidents to ensure they are thoroughly investigated and following the company's policy, monthly x 3 and quarterly thereafter. 4. How the facility will monitor its corrective actions to ensure that the deficient practice will not recur; (e.g., what quality assurance program will be put into place?) (a) The Director of Nursing or designee will bring the results of the following audit to the members of the QAPI team to determine the frequency of future audits.