Transcript Overview of Reporting Unusual Incidents

Reporting Unusual Incidents:
An Overview
Sharon E. Meyer, MPH
Complaint and UIRS Intake Supervisor
Department of Health, Health Care Facilities
Historical Perspective
• IoM Report- 98,000 Deaths
• National Initiatives
• TN Initiatives- Task Forces, TIPS, UIRS
Historical Perspective
• Rules passed for all licensed health care
facilities August 2001
• Interpretive Guidelines/Occurrence Code
Manual posted on state website
• Training provided statewide Summer-Fall
2001
• Electronic System (UIRS) implemented July
2001 for Hospitals and Nursing Homes
Historical Perspective
• Health Data Reporting Act of 2002
introduced winter 2002 and passed on
March 13, 2002
• Prohibits department from releasing
information contained in reports, deems
them undiscoverable as evidence, and
forbids access of reports by subpoena
What Does this Mean to You?
• CONFIDENTIALITY!!!!!
• Rules were amended by Board Aug 2002
• Revisions to interpretive guidelines and
occurrence codes completed May 2002
and 2005
• Reporting Unusual events is a LAW!!!
Definition of Unusual Event
• “Unusual event is an unexpected
occurrence or accident resulting in death,
life threatening or serious injury to a
patient that is not related to a natural
course of the patient’s illness or underlying
condition. An unusual event also includes
an incident resulting in the abuse of a
patient.”
Definition of Abuse
• The willful infliction of injury, unreasonable
confinement, intimidation, punishment with
resulting physical harm, pain or mental anguish
• It is not always clear whether event is an abuse or
a resident to resident altercation in determining
code
• Please provide additional information for this
determination
• Use professional judgement (don’t use 901)
Definition of Neglect
• Failure to provide goods and services necessary
to avoid physical harm, mental anguish or mental
illness
• Often used by NH to report nurse or CNA job
abandonment
• Needed treatments, drugs, therapies, etc., not
provided by individual or facility
• Not protecting non-cognitive residents from
abuse
Definition of Misappropriation
• The deliberate misplacement, exploitation
or wrongful, temporary or permanent use of
a resident’s belongings or money without
the resident’s consent.
Reporting Abuse Requirements
• Previous Code 965- if you use this we know you
have not read the most recent guidelines
• Code 968-Physical Abuse
• Code 969-Sexual Abuse
• Code 963- Rape
• Code 970- Verbal Abuse
• Code 971- Neglect or Self Neglect
• Code 972- Misappropriation of Funds
Reporting Abuse
• CMS requires all unusual events to be
reported within 5 working days
• Certified facilities must follow CMS
timeframe
• Licensed only facilities may report ABUSE in
7 working days
Code 964
• Resident to resident altercations-report only those events
which required physician intervention, e.g., resident sent
out for a psych evaluation, physician changed med orders,
resident went to ER for stitches or derma bond
• Report is done on the victim, give victim demographics,
include perpetrator info and MR# in summary
• Excludes-those events whereby the facility put into place
appropriate and effective interventions that did not
involve the physician (ex. repeatedly redirecting a
resident is not an effective measure over time)
Code 901
• Catch All -originally thought to be used
infrequently but is used very often, falls
with laceration, injuries of unknown origin,
falls with fractures in residents with
osteoporosis (not osteopenia) or other
pathological condition
• Any medical intervention even if soft tissue
Code 751
• Falls with fractures, brain or spinal injury,
internal injury
• Identify the injury in the event summary
• In 2007 approximately 1,363 code 751
reported-all facilities
• Second highest ranking code for NH and all
facilities combined
Elopement Code 923
• State definition-unauthorized exit from the
facility property of a cognitively impaired
resident without staff awareness
• Federal definition-resident going from a safe
environment to an unsafe environment without
staff knowledge
• Two ways to report-send in UIR or call Complaint
Hotline 1.877.287.0010
• Certified facilities-5 days to report
Facility Responsibility
• Maintain current staff roster and email address-if
no email then no messages indicating status of
report-also terminated staff can access your
facility info after they are gone
• When faxing include all of the required
information and make sure writing is legible
• When in doubt about handwriting-TYPE the
narrative on a separate sheet of paper-we will
call you if we cannot read the report
• Make summaries short and to the point-do not put
your CAP in the summary
Facility Responsibility:
• Report incident within 5 or 7 business from
date of identifying event via fax or
electronic system (UIRS) using established
occurrence codes and reporting format
• If reporting via fax, must utilize one-page
event report form developed by
department- similar to JCAHO’s form
• If medication error, complete medication
supplemental form
Facility Responsibility
• Submit Plan of Correction to department
within forty (40) days
• Verify whether plan was acceptable
through written correspondence from
department
• Identify and evaluate measures of
effectiveness on periodic basis
• Enter data into UIRS system on measures of
effectiveness once identified
Health Department
• Department has access to facility records
as allowed in Medical Records Act
• (T.C.A. 68-11-3)
• Department will provide educational
information to facilities and provide Board
with summary of reports each year
• Department can use aggregate data to
develop best practices to improve care for
residents of Tennessee
Department Responsibilities:
• Collect aggregate data of all unusual
incidents reported by facility type and
occurrence code using Centralized
Unusual Incident Reporting
• Follow-up with facility to approve,
disapprove POC or assist with identifying
acceptable actions
Department Responsibilities
• Cite deficiencies where corrective action
is not established or not followed as facility
outlined
• Facilities can be cited for not reporting
events as required and for not reporting in
a timely manner
Reporting Via Fax
• Fax Number : (615) 253-4356
• For information, clinical assistance: (615)
741-7221
Benefits of Reporting via UIRS
• Pending, Incomplete, Accepted, or
Unacceptable status
• Ability to Amend Report if Incomplete
• Ability to Complete Corrective Action Plan
in UIRS- 40 days to Amend Report before
“locked- out”
• Don’t have to mail info to Dept., wait for
response…instant documentation,tracking
In recognition of
YOU
for improving the
health care
and
lives of
Tennesseans!!!