Sun Dial Manor

Review of the provider's 9/9/24 Missing Resident Policy & Procedure revealed that part of the procedure read, An incident report shall be made by the charge nurse providing detailed accounting of the incident in its entirety.

Submit to the state [SD DOH].

Place a copy on Administrator's desk or cc [carbon copy] in email.

The policy also included the following, The charge nurse shall be responsible for documenting the incident in the nursing notes of the resident's chart.

All documentation must be concise and reflect the facts as they relate to the incident including: a.

Times, b.

Persons contacted, c.

Condition of resident upon return to the facility, d.

Physician notification, e.

Physician's orders, f.

Treatment indicated, g.

Any other pertinent information. 11.

Review of the provider's June 2025 Abuse, Neglect, & Misappropriation policy revealed a section regarding investigations that included: 5.

The Investigation Team will review all initial findings and will determine if further investigation is needed.

The Investigation Team will notify the designated state agencies and complete any reports required. 6.

The investigation may include interviewing staff, residents or other witnesses to the incident.

Interview all involved (staff, resident and family) individually, not as a group, so that you can compare their descriptions of the incident in order to determine and inconsistencies.

Any who had contact with the situation should be interviewed. 7.

Corrective action based on the investigation(s) will be completed (e.g., change of procedures, training, discipline or discharge of staff, etc.).Sun Dial Manor shall have evidenced that all alleged violations are thoroughly investigated.

The policy did not specify who was supposed to be on the Investigation Team.

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