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Summary of Investigation
PRIVATE ICF/IID PROVIDER
Case Number: E1312053A Waiver: Private ICF/IID DIDD Investigator: James White
I. Initial Allegation(s):
The person served was transported to the hospital on 12/28/13 and passed away
on 12/29/13. It was reported that while reading documents, it was noted that the
person served was ill at 5:30 AM on 12/28/13. He was not transported to the
hospital until 9:40 AM. It is unknown why the nurse on shift at 5:30 AM, (C. E.),
did not take action in a more timely manner. The person served was diagnosed
with a bowel blockage and respiratory failure. An investigation will be completed
for staffs actions during this death.
II. Conclusion(s):
A. The Administrator shall review the investigation report and will develop a
written corrective action plan. The plan shall be submitted to the regional
office, the Deputy Commissioner of Operations, and the Commissioner within
fourteen (14) calendar days of receipt of the report.
B. The corrective action plan shall address the information contained in the
report and shall also include the following:
1. Corrective and preventative actions that have or will be implemented,
including any disciplinary actions;
2. The timeframe or target date for full implementation of the corrective and
preventative actions;
3. Description of individualized supports that have been provided or offered
to assist the person supported in coping with the event;
4. A response to any incidental information noted by the investigator.
C. It is recommended that the Administrator email the corrective action plan to
DIDDINVPOC.East@tn.gov within fourteen (14) calendar days from the
release of this report. The release date is the day the Office of Investigations
forwarded the report to the Provider via email.
V. Incidental Information:
All of the IFC/IID house managers and staff have been sent an e-mail
reminding them and their staff to call 911 immediately when an emergency
occurs.
CONFIDENTIAL The information contained herein is the property of the Tennessee Department
of Intellectual and Developmental Disabilities and is not to be disseminated or duplicated.
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Per the DIDD Provider Manual, Chapter 18, 18.4.D.4, for Community Providers
and Private ICFs/IID or the Protection from Harm ICFs/IID Policy 100.1.1.VI.K.8 for
DIDD ICFs/IID Facilities, the summary of this investigation should be discussed with the
involved persons served within fifteen (15) business days of the receipt of the report. If
a legal representative has been appointed, they should be invited to participate in this
discussion. The space below has been provided for your convenience as a means by
which for you to document the fulfillment of this requirement.
Printed Name
Witness:
Printed Name
CONFIDENTIAL The information contained herein is the property of the Tennessee Department
of Intellectual and Developmental Disabilities and is not to be disseminated or duplicated.
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