La. Admin. Code tit. 48 § I-9727

Current through Register Vol. 50, No. 5, May 20, 2024

Section I-9727 - Incident Reporting Requirements

A. A nursing facility shall have written procedures for the reporting and documentation of actual and suspected incidents of abuse, neglect, misappropriation of property/funds, and suspicious death. Major injuries of unknown origin (e.g., fractures, burns, suspicious contusions, head injuries, etc.) for which the nursing facility is unable to determine the cause and could possibly be the result of abuse or neglect shall also be reported. Such procedures shall ensure that:

1. a resident is protected from harm during an investigation;

2. all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made or discovered, to the administrator of the facility and to other officials (including Health Standards Section (HSS) and law enforcement) where state law provides jurisdiction, if the events that caused the allegation involve abuse or result in a serious bodily injury; or not later than 24 hours after the events that caused an allegation which does not involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials;

3. allegations of an event that do not involve abuse or result in serious bodily injury shall be reported to the administrator of the facility and HSS not later than 24 hours after the occurrence of or discovery of the incident. The nursing facility shall utilize the current department reporting database system to provide notification;

NOTE: Repealed.

4. appropriate authorities are to be notified according to state law;

5. immediate, documented attempts are made to notify the residents legal representative;

6. immediate attempts are made to notify other involved agencies and parties as appropriate;

7. immediate notification is made to the appropriate law enforcement authority whenever warranted; and

8. the nursing facility is required to maintain internet access and to keep the department informed of its active and monitored electronic mail address at all times.

B. The initial written notification submitted to the LDH HSS within 24 hours of occurrence or discovery of the incident shall include:

1. the name of the alleged victim;

2. the name of the accused (if known);

3. the incident category (if applicable);

4. the date and time the incident occurred, if known, and the date and time the incident was discovered;

5. a description of the alleged abuse, neglect, misappropriation of property, and incident of unknown origin from the victim and/or the reporter;

6. documentation of any action taken to protect the resident during the investigation; and

7. any other relevant information available at the time the report is submitted.

C. The nursing facility shall have evidence that the alleged violations are thoroughly investigated and shall ensure protection of the resident from further potential abuse, neglect, and misappropriation of property/funds while the investigation is in progress.

D. A final report with the results of all investigations shall be reported to HSS within five working days of the incident through use of the current department reporting database system. The report shall include:

1. the alleged victims name, date of birth, and a complete description of the physical harm, pain or mental anguish;

2. the name, date of birth, address and telephone number of the accused. If the accused is a nursing facility employee, include the Social Security number.

3. the date and time the incident occurred, if known, and the date and time the incident was discovered;

4. a description of the alleged abuse, neglect, misappropriation of property, and incident of unknown origin;

5. a detailed summary of the entity's investigation including all witness information and all facts that lead to the determination of substantiated, unsubstantiated or unable to verify:

a. immediate action taken to protect the alleged victim during the investigation; and

b. any action taken toward the accused; and

6. nursing facility administrator/CEO finding.

E. If an alleged violation is verified, the nursing facility shall take appropriate corrective action.

F. If the investigation substantiates abuse, neglect, and/or misappropriation of property against a CNA, the following shall be available, if requested, by HSS:

1. a copy of the NAT-7 verifying termination;

2. the nursing facility abuse policy signed by the CNA;

3. the date and time the incident occurred;

4. the date and time the incident was discovered;

5. a copy of the CNA's statement (signed and dated);

6. a copy of the residents statement (signed and dated);

7. witness statements (signed and dated); and

8. a copy of the time card for the date and time of the incident.

La. Admin. Code tit. 48, § I-9727

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing LR 24:48 (January 1998), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 35:1542 (August 2009), LR 36:1013 (May 2010), Promulgated by the Department of Health, Bureau of Health Services Financing, LR 421900 11/1/2016), Amended LR 49, Amended LR 491075 (6/1/2023).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and 40:2009.1-2009.44.