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Based on interview and record review, the facility failed to timely report the death within 24 hours of restraint removal for 1 of 3 sampled patient (1) to their Center for Medicare Medicaid (CMS) regional office. As a result, there was a delay in regulatory required reporting of a death.

Finding:

Patient 1 was admitted to the facility on 10/9/23 with diagnoses atrial fibrillation (irregular heartbeat) per the admission History and Physical, dated 10/9/23.

A review of Patient 1's medical record titled, Restraint initiation dated, 10/10/23, was conducted. Patient 1 was placed in posey vest restraint at 12 P.M., and the restraint was removed at 4 P.M.

A review of Patient 1's nursing note, dated 10/10/23 at 8 P.M., was conducted. This nursing note indicated, "While receiving report, patient was agitated so[sic] this RN, and offgoing RN ... went into room with MD (medical doctor) (name of MD) present. Suddenly patient become unresponsive aystole [sic] on monitor, pulse was checked and when non-present compressions and code blue was called and started ..."

A review of Patient 1's Code Blue Record, dated 10/10/23, was conducted. At 7:26 P.M., Patient 1 was pulseless, and CPR (cardiopulmonary resuscitation) was started. Patient 1 was intubated (inserting a tube into mouth or nose to help breath) at 7:29 P.M., Patient 1 remained pulseless. At 7:46 P.M., Patient 1 was declared dead by the physician.

An interview with the clinical nurse specialist (CNS) on 10/25/23 at 9:56 A.M., was conducted. Per CNS, Patient 1 expired on 10/10/23 and the facility did not report it to CMS until 10/16/23, which was 6 days after the event occurred. The CNS stated facility leadership staff were not aware of the reporting timeframe to CMS. CNS stated, "It's a little late."

A review of facility policy and procedure titled, Restraint and Seclusion use, dated 7/8/22, was conducted. This policy indicated, " ...a. All other reports other than wrist restraints will be made to CMS by telephone, facsimile, or mail no later than the close of business the next business day following knowledge of the patient's death ..."