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!!!