Critical Incident Reporting 535-05-57

(NEW 6/15/20 ML# 3583)

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Critical Incident

In order to assure the necessary safeguards are in place to protect the health, safety, welfare of all clients receiving HCBS, all critical incidents (as defined in this chapter) must be reported and reviewed (as described in this chapter). The goal of the incident management system is to proactively respond to incidents and implement actions that reduce the risk of likelihood of future incidents.

This chapter includes all consumers receiving personal care service, including those that receive MSP-PC in a Basic Care setting.

A critical incident is any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety or well-being of any client receiving HCBS.

Reportable Incidents

1. Abuse (physical, emotional, sexual), neglect, or exploitation
2. Rights violations through omission or commission, the failure to comply with the rights to which an individual is entitled as established by law, rule, regulation, or policy
3. Serious injury or medical emergency, which requires care that would not be routinely provided by a primary care provider
4. Wandering or elopement
5. Restraint violations
6. Death of any HCBS client who has an open case, regardless of where the death occurred or if it was witnessed by the provider. A Report of a client death must include and the cause (including death by suicide)
7. Medication errors or omissions

• Medication errors that occur in a setting other than a basic care facility include all medication errors and omissions
• Medication errors in a basic care facility are defined to align with the reporting requirements of the Department of Health. A reportable medication error for the purposes of this chapter is defined as “a medication error by facility staff member which results in a negative outcome to a resident or a pattern of medication errors”

8. Any event that has the potential to jeopardize the client’s health, safety or security if left uncorrected

HCBS Case Manager will follow up with all reported critical incidents.

If HCBS Case Manager has first-hand knowledge of a critical incident, follow incident reporting requirements.

Apart from a critical incident that occurs within a basic care facility, if the case involves abuse, neglect or exploitation, a formal VAPS (Vulnerable Adult Protective Services) referral will be initiated according to ND Century Code 50-25.2-03(4). VAPS will be responsible for independent review and follow up.

If the incident involves a provider, the complaint protocol will be followed to determine the next steps, which may include involving law enforcement.

Incident reporting requirements

Any paid provider or paid family member who is with a client, involved, witnessed, or responded to an event that is defined as a reportable incident, is required to report the critical incident. If the incident is a death an incident report must be completed even if the death is not witnessed by the paid provider or paid family member.

As soon as a paid provider or paid family member learns of a critical incident involving a client, the incident must be:

1. Reported to the HCBS Case Manager and
2. Complete an incident report (SFN 53601 – Risk Management Medical Services Incident Report).

1. SFN 53601 is found here: https://www.nd.gov/eforms/Doc/sfn53601.pdf
2. The completed SFN 53601 is to be forwarded to the HCBS Case Manager within 24 hours of the incident.
3. The HCBS Case Manager will forward to Aging Services.

Examples

Example 1: If a client falls while the QSP is in the room but the client didn’t sustain injury or require medical attention, a critical incident report is not required.

Example 2: If a family member informs the case manager that a client is in the hospital due to a stroke, a critical incident report is not required because the case manager nor QSP witnessed or responded to the event. If the client dies while in the hospital an incident report must be submitted if the client’s HCBS case is still open.

Example 3: If a QSP comes to a client’s home and the client is found on the floor and the QSP calls 911 so the client may receive medical attention, a critical incident report is required because the client required medical attention AND the QSP responded to the event (fall).

Example 4: If a client was not given a dose of digoxin and developed heartbeat irregularity a critical incident report is required because the medication error resulted in a negative outcome.