6216 Documenting a NHT Sentinel Event Report | ACCESS-TO-SERVICES-5200-MANUAL
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Georgia Division of Aging Services |
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Chapter: |
6000 Community Transitions |
Effective Date: |
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Section Title: |
Documenting a NHT Sentinel Event Report |
Reviewed or Updated in: |
MT 2017-01 |
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Section Number: |
6216 |
Previous Update: |
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Summary Statement
Nursing Home Transition Agencies use the Sentinel Event Report (SER) to communicate critical incidents to Division of Aging Services.
Basic Considerations
Definitions
A sentinel event is defined as one of the following:
- Abuse
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As defined by OCGA 30-5-3 (1); refer to Adult Protective Services Manual, Chapter 1, Section 2001.5.
- Neglect
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As defined by OCGA 30-5-3 (9); refer to Adult Protective Services Manual, Chapter 1, Section 2001.5.
- Exploitation
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As defined by OCGA 30-5-3 (8); refer to Adult Protective Services Manual, Chapter 1, Section 2001.5.
- Hospital / Nursing Facility / ICF Admit
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Client is admitted to a hospital, nursing (or skilled nursing) facility, long-term acute care, in-patient hospice, or similar facility for more than twenty-four (24) hours. Scheduled medical procedures/surgeries can be omitted from this report.
- Repeated Use of Emergency Room
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The NHT Client repeatedly visits an emergency room seeking treatment, prescriptions, or other medical care. Repeatedly is defined as more than once in a 30-day period.
- Other
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The TC believes a critical incident has occurred but cannot explain it with one of the categories above.
Standards of Promptness
All Sentinel Event Reports are entered into the DAS Data System within three (3) business days of the time the sentinel event becomes known to the TC. The date of the incident and the date of the report are to be listed separately on the report.
Reporting Standards
All Sentinel Event Reports will be logged into the DAS Data System. Paper copies are not accepted as reports.
The original SER should be updated as often as necessary to capture updates to the initial event described. Additional SERs are not required unless information becomes available that would trigger a second SER category.
DAS Procedures
The following are the process and procedures by which DAS NHT Program staff will evaluate SERs.
NHT Program Staff review SER documentation monthly. SER reviews answer the following questions:
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Is information accurate?
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Were standards of promptness observed?
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Did the Transition Coordinator (TC) adhere to policy and procedure in response to the event?
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If an action plan was required, was it conducted using a person centered approach using independent living philosophy?
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Is documentation surrounding the event informative and written according to standards and/or training?
If, during review, deficits are noted, a Plan For Improvement (PFI) will be drafted based on the elements above. A plan for improvement is a statement from Division of Aging Services informing the NHT agency that deficits exist. The PFI is an informative tool only. The PFI would refer to standards, policy, procedure, or general practice that should be reviewed to assure the deficit noted is corrected in future work. It may ask for document correction and resubmission.
If significant deficits are present or multiple PFIs indicate more significant action is necessary, a Corrective Action Plan (CAP) may be drafted. A CAP requests the staff at the NHT agency to address the deficits in the program. A CAP has specific, measurable goals to address the deficit within a reasonable timeframe.
NHT Agency Procedures
The procedures below are formatted to follow the flow of the SER report document. The standards are the guide by which the document is completed.
Process By Category
Abuse / Neglect / Exploitation (ANE)
As mandated reporters, NHT agency staff are required to report any instances of abuse, neglect, or exploitation to Adult Protective Services and law enforcement in addition to the programmatic reporting done through the SER. If an NHT client is a victim, or the TC suspects they are a victim, of abuse, neglect, or exploitation a SER should be completed.
Hospital / Nursing Facility / ICF Admission
If the NHT TC discovers the client has been admitted to a facility, for any of the reasons above (ANE), an SER is to be completed.
Repeated Emergency Room Visits
Repeated use of the ER, or using the ER as a primary physician is a key precursor of nursing home placement. NHT TCs should be diligent in assisting clients in obtaining a regular primary care physician. The NHT TC does not assume transportation responsibility to physician visits.
Summary / Participant Reporting / Adverse Outcomes
The NHT TC makes contact with the principal individuals associated with the Sentinel Event to determine the facts of the incident. The MFP Participant is always contacted regarding an SER. Other principal individuals may include the related physician, personal support aide, case manager, facility staff, family, friends, or other members of the circle of support. TCs are expected to investigate the incident thoroughly to provide complete and informative documentation related to the event.
If the TC is unable to make contact with the principals prior to the standards of promptness, this should be noted on the report, and the report submitted. An update to the report should then be submitted once additional information is obtained.
Witnesses / Alleged Participants
List individuals who witnessed the event or originally discovered the status of the client.
Action Plan
An action plan must be developed to address the root cause of the sentinel event. If it is determined that an NHT Transition Service could be utilized to help address the root cause, the TC will then:
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Work with the client to address the root cause and determine the good/service that can be utilized.
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Procure the good/service that could assist the client to reduce the likelihood of similar events in the future in a reasonable timeframe.
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Review the effectiveness of the solution at each subsequent monthly contact until the TC is assured the best solution was identified.