Stop Over-reporting or You’ll Get Burned!

One of the easiest ways to get tags cited in your facility is to invite the State to pay you a visit.  Self-reports of unusual incidents can and will get you deficiencies.  Let’s say you discover something in your facility that went wrong and had a negative outcome.  Most of the time, it is almost like a race to make sure the facility gets the report in to the State timely.  You get the initial report in and ….what?  You’ve done your duty and now you can move on to something else, right?  Not quite.

You see, self-reports are still COMPLAINTS that must be investigated.  If you report it, the STATE will come.  Now, I’m not telling you not to report the things you are obligated to.  I’m telling you to know your regs and avoid reporting issues that are not required to be reported.

Let me give you an example:

A nursing home resident fell in her room and fractured her hip.  This is a serious issue and the nursing home’s response was appropriate.  The resident was immediately sent to the ER for evaluation.  Notified the family and physician as required.  The RN Supervisor also reported the incident to the State due to the serious nature of the injury.

A week later the complaint surveyor showed up to investigate.  She found that the fall was likely related to the resident attempting to toilet herself.  The resident was not on any toileting plan though documentation in her medical record seemed to support he opinion that the facility should have tried.  Unfortunately, while in the building the surveyor also decided to observe some other direct care.  Of course, it wasn’t long before problems were identified.  One CNA who was assisting a resident with incontinence care accidentally left a moisture barrier / skin protectant product in the room of a dementia resident.

The facility ended up getting several tags including a G-tag (actual harm) for the fall with fracture and a J-tag (immediate jeopardy) for the cream.  There are several problems with this whole situation.

First, no incident should ever be reported to the State without the administrator’s review and blessing.

Secondly, the RN Supervisor is not the person to make an unusual event reporting decision.  She didn’t know the regs and that the reporting process in that state allowed serious injuries that are related to pre-existing conditions to be excluded from the reporting requirements.

No one reviewed the resident’s actual condition before the fall.  Since the resident had a pre-existing condition of osteoporosis and demineralization of the bone, ANY fall or accident could easily result in a fracture.  If a nursing home resident has such a diagnosis, you would EXPECT a fracture.  It is no longer considered an UNUSUAL event.

Bottom-line, this facility reported an incident – that could happen anywhere in any facility – that they didn’t have to.  It resulted in severe deficiencies, tens of thousands of dollars in penalties, and just a bad day for all.

Know your regs and reporting processes.  Don’t over-report.  Avoid bringing surveys upon yourself when it’s unnecessary.


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