1. Reporting Unusual Incidents: An Overview
Sharon E. Meyer, MPH
Complaint and UIRS Intake Supervisor
Department of Health, Health Care Facilities

2. Historical Perspective
IoM Report- 98,000 Deaths
National Initiatives
TN Initiatives- Task Forces, TIPS, UIRS

3. 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

4. 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

5. 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!!!

6. 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.”

7. 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)

8. 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

9. 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.

10. 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

11. 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

12. 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)

13. 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

14. 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

15. 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
Certified facilities-5 days to report

16. Facility Responsibility
Maintain current staff roster and address-if no 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

17. 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

18. 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

19. Health Department
Department has access to facility records as allowed in Medical Records Act
(T.C.A )
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

20. 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

21. 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

22. Reporting Via Fax Fax Number : (615) 253-4356
For information, clinical assistance: (615)

23. 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

33. In recognition of
YOU
for improving the
health care
and
lives of
Tennesseans!!!