Sentinel Events and Incidents 624-05-15-50-33

(Revised 1/1/24 ML #3889)

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A. Sentinel Event

A sentinel event is defined as any unexpected occurrence involving death or serious physical or psychological injury or risk thereof that is not related to the natural course of the individual’s illness or underlying condition. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called sentinel because they signal the need for immediate investigation and response by the custodial agency. Examples of a sentinel event that could occur during the course of foster care episode are:

  1. Serious physical injury: defined as an occurrence that places the child in serious or critical condition as determined by a medical professional. This may include suicide attempt, which is defined as when a child in foster care harms themself with any intent to end their life but does not die as a result of their actions. This category also includes the death of a foster child for any reason.

  2. Serious psychological injury: defined as involvement in significant violence, torture, or inappropriate restraints. This may also include child in foster care involvement with wrongful use of firearms or a kidnapping.

  3. Inappropriate sexual contact: defined as sexual abuse/assault involving the foster child in any way.

 

B. Incidents

An incident is an unplanned occurrence that resulted or could have resulted in injury to a child in foster care. An example of an incident would be if a child in foster care runs away, law enforcement involvement with a child in foster care, or a 960 report of suspected child abuse involving child in foster care.

 

Responsibility of Custodial Agency

 

A custodial worker witness to or having knowledge of an incident or sentinel event must immediately send a report. The case worker is responsible for notifying the child’s Biological Parent(s), Agency’s Director, Supervisor, and CFS Field Service Specialist. Notification can be made by phone, voicemail, or e-mail as soon as possible, but no later than twelve (12) hours after the occurrence. Incident information must include:

  1. Name of the child and FRAME#

  2. Date, time, and place of incident

  3. Name and address of primary caregiver and placement at time of the incident

  4. Brief description of the incident; outcome if known, and next steps

  5. If biological family was notified

 

In the event of a runaway child in foster care, the custodial agency is responsible for following Missing Children Policy 624-05-15-50-34.

If the case worker is uncertain whether a situation is a sentinel event or an incident, consultation is available through their assigned CFS Field Service Specialist.

 

Responsibility of CFS Field Service Specialist

 

CFS Field Service Specialists must enter all incidents and sentinel events into the ND OMB Risk Management incident reporting system https://incidentreporting.omb.nd.gov/ within 24 hours of being notified.

Any subsequent information (not to include a SFN 960 unless requested by authorized staff) must be attached to the initial incident report with State Risk Management OMB and also sent to the DHS Risk Manager.

CFS Field Service Specialist will make notification of Sentinel Events to: cfssentinel@nd.gov and include other individuals as needed.