State Veterans Home Sentinel Events

1. State Veterans HomeSentinel Events Valarie Delanko, RDN, LDN, CPHQ National SVH Program Manager for Quality and Oversight VACO GEC

2. Objectives • To define a State Veterans Homes (SVH) Sentinel Event. • To understand what the SVH is required to report to the Medical Facility Director of jurisdiction. • To understand the SVH reporting timeframes. • To understand what the SVH is requested to report to the Medical Facility Director of jurisdiction. • VACO GEC tracking of SVH sentinel event reporting.

3. Defined Sentinel Event • State Veterans Homes mustreport sentinel events to the VA Medical Center Director of Jurisdiction as outlined in 38 CFR Part 51.120. • A sentinel event is an adverse event that results in the loss of life or limb or permanent loss of function. Examples of sentinel events are as follows: (i) Any resident death, paralysis, coma or other major permanent loss of function associated with a medication error; or (ii) Any suicide of a resident, including suicides following elopement (unauthorized departure) from the facility; or

4. Defined Sentinel Event (iii) Any elopement of a resident from the facility resulting in a death or a major permanent loss of function; or (iv) Any procedure or clinical intervention, including restraints, that result in death or a major permanent loss of function; or (v) Assault, homicide or other crime resulting in patient death or major permanent loss of function; or (vi) A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall.

5. Sentinel Event Required/Timeline • 38 CFR part 51.120: (3) The facility management must report sentinel events to the director of VA medical center of jurisdiction within 24 hours of identification. The VA medical center of jurisdiction must report sentinel events by calling VA Network Director (10N 1-22) and Chief Consultant, Office of Geriatrics and Extended Care within 24 hours of notification.

6. Sentinel Event Reporting • What is the SVH required to do once they identify a sentinel event? • 38 CFR Part 51.120:(4) The facility management must establish a mechanism to review and analyze a sentinel event resulting in a written report no later than 10 working days following the event. The purpose of the review and analysis of a sentinel event is to prevent injuries to residents, visitors, and personnel, and to manage those injuries that do occur and to minimize the negative consequences to the injured individuals and facility.

7. Sentinel Event Reporting • Each one of these required elements to the regulation is reviewed by VACO GEC on each submitted event: • The State or SVH determines their own mechanism…the SVH should not be asked nor required of them to perform an RCA, or PDSA cycle…the SVH can develop their own process and structure. • The SVH must send a written report to the Medical Facility Director in 10 business days of the known event. • It must be a review and analysis NOT a timeline.

8. Requested Reports • State Veterans Homes are requestedto report events to the VA Medical Center of Jurisdiction that they would normally report to their respective state in accordance with State Law. Since State law varies, VA Central Office hasrequested that State Veterans Homes provide to the Director, VA Medical Center of Jurisdiction reportable events that are high profile or based on citations in various section of 38 CFR 51 and 52. (10N Guide to Issue Briefs, VA internal document.)

9. Requested: Events that occur in a State Veterans Home that are requested to be provided to the VA Medial Center of jurisdiction are as follows: • Substantiated allegations of mistreatment, neglect, abuse, or misappropriation of resident property; • Elopements, pursuant to state regulations; • Infectious outbreaks (Definition - Infectious Outbreak:Events reportable to Public Health agencies pursuant to state regulations); • Resident to resident or resident to staff altercations resulting in any injury that is other than minor;

10. Requested: Con’t • When an adverse event occurs which is not determined to be a Sentinel Event, but the respective State requires that the occurrence be reported to the State, the VA medical center of jurisdiction can request that the State Veteran Nursing Home also report it to the VA medical center of jurisdiction; • Inspection / Survey reports by oversight agencies; • Information regarding the SVH that appears in local or national media; • The VA medical center of jurisdiction can request that falls with significant injury which require the resident to be sent out of the facility for medical intervention be reported.

11. Questions?Please contact:Valarie Delanko, RDN,LDN,CPHQNational SVH Program Manager for Quality - VACO814-860-2201