F0609

E

Failure to Timely Report Facility Incidents and Investigation Results to SD DOH

Flandreau, South Dakota Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely submit initial and final Facility Reported Incident (FRI) reports to the South Dakota Department of Health (SD DOH) for multiple residents who experienced reportable events, including alleged abuse, falls with injury, and other serious incidents. For one resident who reported an allegation of abuse on 1/3/26 at 6:00 p.m., the initial report was not submitted until 1/14/26 at 9:45 a.m., approximately 11 days after the event, and the final investigation report was submitted on 1/16/25, outside the required time frames. The SD DOH complaint record stated the facility failed to ensure timely reporting for this resident and that the delay failed to ensure immediate protection and oversight. The administrator acknowledged awareness of the required reporting time frames and responsibility for reporting but could not identify why the reports were not completed on time.

The facility also failed to meet reporting requirements for several residents who had falls requiring further medical evaluation. One resident had a fall with a head laceration requiring staples on 12/28/25 at 9:45 p.m.; the initial report was not submitted until 12/29/25 at 8:37 p.m., exceeding the 2‑hour requirement, and the final report was not received until 1/20/26, beyond the 5 working‑day requirement. The SD DOH complaint record stated this failure placed the resident at risk for unaddressed abuse or neglect. The same resident had another fall with a head laceration on 1/4/26 at 2:28 p.m.; while the initial report was timely at 3:29 p.m., no final investigation report was ever submitted. Another resident had a fall on 10/13/25 at 4:18 p.m. with head and pelvic pain; the initial report was timely, but the SD DOH rejected the report twice requesting a final investigation, and no final report was submitted. The DON stated the final investigation report “got stuck in the cracks.”

Additional residents experienced falls with injuries or serious symptoms for which the facility did not meet initial or final reporting requirements. One resident had a fall with a head laceration on 11/5/25 at 8:55 p.m.; the initial report was not submitted until 1:41 p.m. the next day, exceeding the 2‑hour requirement, and no final report was submitted despite SD DOH rejections and requests. Another resident had a fall with a seizure on 11/16/25 at 7:30 p.m.; the initial report was not received until 7:11 p.m. the following day, and no final investigation report was submitted. A different resident had a fall with head impact and seizure on 12/5/25 at 9:05 p.m.; the initial report was submitted the next day at 12:12 p.m., and the final report on 12/15/25, both beyond required time frames. One resident sustained a left arm fracture from a fall on 12/17/25 at 5:30 a.m.; the initial report was not received until 12/29/25 at 9:29 p.m., and no final report was submitted, with documentation showing inconsistent event dates. Another resident was involved in alleged potential resident‑to‑resident physical abuse on 11/21/25 at 7:00 a.m.; the initial report met the 24‑hour requirement, but no final investigation report was submitted.

Interviews with the administrator and DON confirmed that they were responsible for completing initial and final FRI reports to the SD DOH and that they were aware of the state’s required time frames: allegations, falls of unknown origin, and falls with major injury to be reported within 2 hours, and all other incidents within 24 hours, with final investigation reports due within 5 working days. The administrator acknowledged the facility had issues with reporting FRIs and stated that staff were to call her or the DON at any time to inform them of incidents so they could determine reportability. She reported that all managers had completed education on reportable incidents, and about half of all staff had completed related education by the time of the survey. The facility’s Abuse Reporting and Response policy required immediate reporting of suspected or alleged abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source, and mandated reporting of investigation results to the state survey agency within 5 working days, but the documented events and complaint records showed repeated failures to follow these requirements for nine residents.