RESIDENT RIGHTS 04-02-013
UNUSUAL INCIDENTS
POLICY STATEMENT.
The Division of Veterans Healthcare Services (DVHS) requires that each New Jersey Veterans Memorial Home (VMH) develops and implements a process that assures the prompt reporting and investigation of unusual incidents, and the timely notification of the involved licensing/regulatory agencies.
PURPOSE.
To initiate a process that facilitates the reporting, investigation, and remedy of unusual incidents, and to facilitate corrective actions designed to prevent and/or eradicate incidents of verbal, physical, emotional, financial or sexual abuse, neglect, exploitation or misappropriation of resident property.
INCIDENT REPORT GUIDELINES.
A. The Incident Report / investigation should never be a part of the Medical Record.
B. Information in the Incident Report should be factual and contain no opinions or assumptions.
C. Comments as to how the incident could have been prevented should not be included in the Incident
Report.
D. The Incident Report / investigation is "CONFIDENTIAL." The number of copies and people
who have access to these documents should be limited. The Chief Executive Officer or designee must approve requests for copies.
DEFINITIONS.
UNUSUAL INCIDENT - any event that occurs that can lead to serious consequences. Incidents may involve residents, staff members, visitors, volunteers or contracted associates within the New Jersey Veterans Memorial Home facility. Unusual Incidents include, but are not limited to:
ABUSE – the willful infliction of physical pain, injury, or mental anguish. Abuse can be physical, psychological, financial, sexual, verbal, and/or emotional. Abuse can be neglect or unreasonable confinement. Abuse can also be the willful deprivation of services which are necessary to maintain a person's physical and/or mental health, or the denial of civil or constitutional rights.
FINANCIAL ABUSE – financial abuse is the theft or misuse of a resident’s funds, property, or assets, or the illegal or unauthorized use of a resident’s property, money, possessions, or other valuables. Examples of this include stealing a resident’s money or possessions, forging the resident’s signature, cashing the resident’s check(s) without authorization, using the resident’s telephone to make unauthorized long-distance telephone calls, misappropriation of the resident’s property, and so forth.
MENTAL ABUSE / PSYCHOLOGICAL ABUSE – this includes, but is not limited to, humiliation, harassment, ignoring a resident, verbal assaults such as shouting or swearing, frightening, threats of punishment, isolation, or deprivation.
RESIDENT RIGHTS 04-02-013
-2-
UNUSUAL INCIDENTS
PHYSICAL ABUSE – includes, but is not limited to, hitting, slapping, pinching, pushing, burning, kicking, etc. It also includes controlling behavior through corporal punishment, the use of unauthorized physical or chemical restraints, or deprivation of food, water and basic care needs.
*SEXUAL ABUSE – sexual abuse is forcing a person to take part in any sexual activity without his or her consent. It includes, but is not limited to, sodomy, incest, rape, exhibitionism, French kissing, masturbation, fondling, oral sex, anal sex, pornography, foreign-body penetration, sexual harassment, sexual coercion, or sexual assault. (*Follow Sexual Abuse Procedure 04-02-014 for additional instructions)
VERBAL ABUSE – verbal abuse includes oral, written, or gestured language that willfully includes disparaging, derogatory, and/or threatening terms directed towards the resident or family member, or within hearing distance of the resident or family member.
MISTREATMENT - obvious signs of resident distress and/or injury, causing the resident to feel abused, intimidated, frightened or fearing that his/her life or safety is being threatened.
INVOLUNTARY SECLUSION - the separation of a resident from other residents, or confinement to his/her room against the resident’s will.
EXPLOITATION - the act or process of using a person or their resources for another person's profit or advantage, without the legal entitlement to do so.
NEGLECT – the willful deprivation of services, the intentional or unintentional failure of an individual to provide for or to maintain the care and safety of residents under their supervision, including but not limited to, failure to provide and maintain proper and sufficient food, clothing, medication, health and/or physical care, shelter and/or supervision.
IMMINENT DANGER - is a situation that could reasonably be expected to cause death or serious harm to residents or staff before the danger can be eliminated through corrective action. The police should be contacted immediately.
INTERVENTION TECHNIQUES - uses of behavioral intervention techniques, which are a part of an approved Behavior Modification Plan within the treatment plan, shall not be considered to be abuse or neglect.
ADVERSE EVENT - refers to a broad category of untoward incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided within the jurisdiction of the VMH. This includes events that occur while in the VMH or out of the facility for treatment or follow-up. For the purpose of this procedure, adverse events are limited to those which, while not determined to be Sentinel Events, are subject to required reporting for New Jersey.
SENTINEL EVENT - A category of Adverse Event. Sentinel Events are unexpected occurrences involving death, serious physical/psychological injury, or risk thereof. Serious injury specifically will include loss of limb or function. The phrase “risk thereof” includes any process variation for which a
RESIDENT RIGHTS 04-02-013
-3-
UNUSUAL INCIDENTS
recurrence would carry a significant chance of serious adverse outcomes. The VMHs, in partnership with the VAMCs of jurisdiction, use this framework which originates from JCAHO.
ACTS OF ABUSE INCLUDE, BUT ARE NOT LIMITED TO - any act or omission that deprives a veteran home resident of their rights or which has the potential to cause, or causes, actual physical injury or emotional harm or distress. Acts that cause pain, cuts, bruises, loss of body function, sexual abuse, temporary or permanent disfigurement, death; striking with a closed or open hand; pushing to the ground or shoving aggressively, twisting a limb, pulling hair; withholding food; forcing a resident to eat obnoxious/ unhealthy food; use of verbal or other communication to curse, vilify, degrade a resident or threaten with physical injury,
A. All cases of suspected abuse.
B. Any death that resulted from an accident, an injury, or is suspicious in nature.
C. Threats of Violence (i.e., intent to do bodily harm, assault, bombs, etc.).
D. Serious injuries such as suspicious burns, second/third degree burns, avulsion of
teeth, lacerations requiring sutures, fractures and suspicious bruises.
E. Any incident that might draw newsworthy public attention.
F. Thefts
INTERNAL REPORTING RESPONSIBILITIES.
A. All employees shall:
1. Immediately report unusual incidents, suspected or alleged cases of abuse, exploitation, neglect, imminent danger and assault to their Supervisor or Department Head.
2. Cooperate with the investigator and provide written statements prior to the end of the tour
of duty.
3. Immediately intervene to assist the resident if the employee witnesses an unusual incident or a suspected case of abuse, exploitation, neglect, imminent danger, or assault. The employee shall not be expected to put themselves in jeopardy, and shall request assistance as needed.
B. The Department Head/ immediate supervisor/ designee shall:
1. Ensure that medical treatment is obtained/provided, as appropriate.
2. Complete the Preliminary Unusual Incident – Sentinel Event Report Form, NJDMVA Form 6, MAR-89 (REV. 10 / 01).
3. Provide a copy of the employee assignment schedule.
RESIDENT RIGHTS 04-02-013
-4-
UNUSUAL INCIDENTS
4. Forward the completed Preliminary Unusual Incident – Sentinel Event Report Form, staff
assignment schedule, and the statements of all witnesses and staff on duty to Administration prior to the end of the tour of duty.
5. Notify the facility Administrator in all situations of alleged or suspected crimes, abuse, exploitation, reportable fires defined by DOH, disasters, emergency transfers, emergency evacuation, elopement, and all resident deaths that are suspicious in nature. Thefts over $200.00, for the purpose of reporting, shall be considered a reportable crime.
a. Record the name of the Administrator/designee, date, and time of notification on the
Preliminary Unusual Incident – Sentinel Event Report Form.
b. Notify the New Jersey Department of Health and Senior Services immediately by phone at 1-800-792-9770, or after hours notify the New Jersey State Operator at (609) 392-2020.
c. Notify the New Jersey Office of the Ombudsman for the Institutionalized Elderly at 1-877-582-6995 or (609) 943-4023 that an institutionalized elderly person (60 years old or older) is being, or has been, abused, neglected or exploited.
d. Notify the Veterans Administration Medical Center (VAMC) of jurisdiction in the event the unusual incident results in a Safety Assessment Code (SAC) score of three or greater on the SAC Matrix scoring scale.
6. Notify the Police immediately in all situations of thefts over $200.00, crimes, abuse,
exploitation, reportable fires defined by DOH, disasters, emergency evacuations, residents considered as "missing" from the facility, deaths which are suspicious in nature.
a. Record on the Preliminary Unusual Incident – Sentinel Event Report Form, the name of
the Police Officer, the jurisdiction, and the date and time of notification.
7. Notify the Medical Director/ Nursing Supervisor/ Social Services Representative who will
contact the family representative/guardian and inform them of the incident as soon as possible, in accordance with New Jersey Department of Health and Senior Services standards.
8. Forward all completed information/ report forms to the Administrator/designee.
C. In the absence of the Department Head/ Supervisor/ designee, the person responsible for the unit,
program, or service, shall initiate the Preliminary Unusual Incident –Sentinel Event Report Form and ensure the completion of all items identified in Internal Reporting Responsibilities (above).
D. The Administrator/ designee will complete the Preliminary Unusual Incident – Sentinel Event
Report Form, NJDMVA 6 – MAR-89 (REV. 10/01). The Report shall contain:
RESIDENT RIGHTS 04-02-013
-5-
UNUSUAL INCIDENTS
a. Written statements from all employees on duty and within the resident's assigned area
at the time of the incident, and other witnesses. With the consent of the resident, video taping may be conducted. The resident must be competent and willing to have their account of the incident video taped. When taping only the investigating officer, preliminary investigator, camera operator, and a social worker or other person as requested by the resident (to serve as the resident’s advocate) may be present. Statement must include: who, what, when, where, how. These are defined as:
WHO - Resident is to be identified by name and number. Employee is to be identified by name and title. The writer, at the conclusion of their statement, must print full name and title, followed by signature. All statements must be dated.
WHAT - Explain, in detail, what happened, the contributing facts as they relate to the incident, also explain what the employee was doing at the time of the incident. If the writer of the statement did not witness the incident, they must indicate that fact.
WHEN - The exact time and date the incident occurred.
WHERE - Exact location of the incident, (i.e., Bathroom "A" wing, century tub area.)
HOW - Document the sequence of events that occurred with regard to the incident.
2. The "Final" Incident Report, completed by the Administrator/designee, on all Unusual
Incidents must include:
a. The resident’s medical history, behavior, or other important details that may be related
to the incident.
b. A summarization of all the facts related to the incident. (Narrative, in chronological
order.)
c. A list of physical evidence, if any.
d. Essential information such as Medical/Clinical, Nursing Service Accident/Injury Reports,
all other pertinent information and records.
e. Preliminary/final conclusions, based on the results of the investigation of the facts, which
will prove or dismiss the allegation.
f. Recommendations. All recommendations are to be based upon the Preliminary
Incident Report and "Final" Incident Report conclusions, and reviewed by the appropriate Department Head/ Supervisor for follow-through.
g. Attachment of all Incident Report Statements.
RESIDENT RIGHTS 04-02-013
-6-
UNUSUAL INCIDENTS
3. The Investigating Officer (Administrator/designee) is responsible to ensure that the final report is submitted to the CEO within five (5) days, unless an extension is approved. The Division Director must approve any extensions of reports to be submitted to DVHS.
EXTERNAL REPORTING RESPONSIBILITIES.
A. The Department Head/immediate supervisor/designee shall, in the absence of an Investigating
Officer/Administrator/Administrator On-Call or Director of Nursing Services, notify:
1. The New Jersey Department of Health and Senior Services immediately by telephone at 1-800-792-9770 during business hours, or after hours notify the State Operator at (609) 392-2020, followed within 72 hours by written confirmation of any of the following:
a. Interruption of three (3) or more hours of basic physical plant services, or temporary loss of
a major system (electric, water, heating, AC) that cannot be repaired within 24 hours.
b. All alleged or suspected crimes which endanger the life or safety of residents or
employees, which have also been reported at the time of occurrence to the police
department, and which result in an immediate on-site investigation by the police.
c. All fires, disasters, deaths and imminent dangers to a resident’s life or health resulting
from accidents or incidents in the facility.
d. The evacuation of residents from the facility.
e. Significant infectious outbreaks.
f. Elopement of a resident.
2. The New Jersey Office of the Ombudsman for the Institutionalized Elderly immediately by telephone, 24 hours per day, at 1-877-582-6995, of any suspected resident abuse, neglect or exploitation of any residents age 60 years or older.
3. Notify the Veterans Administration Medical Center (VMAC) of jurisdiction in the event the unusual incident results in a Safety Assessment Code (SAC) score of three or greater on the SAC Matrix scoring scale.
4. Chief, Enforcement Bureau, Drug Control Unit, New Jersey Department of Law and Public
Safety, Division of Consumer Affairs, P.O. Box 45045, 124 Halsey Street, 3rd floor, Newark, New Jersey 07101, (973) 504-6351 or (973) 504-6545, regarding any unusual drug shortages.
5. The Director of Veterans Healthcare Services (DVHS), New Jersey Department of Military
and Veterans Affairs (NJDMAVA), of all Category "A" Unusual Incidents as soon as possible, or by 10:00 AM of the first business day following the incident.
RESIDENT RIGHTS 04-02-013
-7-
UNUSUAL INCIDENTS
6. Completed investigations for Category "A" Unusual Incidents must be sent to the Director of
Veterans Healthcare Services within five (5) days.
REPORTING SENTINEL EVENTS.
A. Facility management must report identified Sentinel Events to the Veterans Administration Medical
Center (VMAC) of jurisdiction, and to the Director, Division of Veterans Healthcare Services, within 24 hours. A review and analysis of the Sentinel Event, in a written report, will be facsimiled no later than ten (10) business days after the date of the event, as follows:
1. Sentinel Events signal the need for immediate investigation and response. Immediate
investigations may include a Root Cause Analysis (RCA) or, in the case of an Intentionally
Unsafe Act, administrative action.
B. Some examples of a Sentinel Event include:
1. Death resulting from a procedure or clinical intervention, such as nasogastric tube
solutions that infiltrate the lungs, or restraint/mattress/bedrail/blanket/pillow-induced
compression asphyxiation episode resulting in suffocation.
2. Death resulting from medication error or other treatment related error (wrong time, wrong
route, wrong patient, wrong dose, wrong medication);
3. An injury associated with the use or nonuse of a drug;
4. Suicide of a patient in or around the New Jersey Veterans Memorial Home (VMH) while
under the care of the VMH, or while on temporary leave from the VMH;
5. Para-suicidal Behaviors – Any suicidal behavior with or without physical injury [i.e.,
short of death], including the full-range of known or reported attempts, gestures, and
threats. NOTE – Because suicidal behavior, attempts, gestures and threats may be defined
and/or interpreted differently among States, follow the State requirements for reporting and
determination as to whether the event is to be considered Sentinel.
6. Surgery on the wrong patient or body part regardless of the magnitude of the operation;
7. Hemolytic transfusion reaction involving the administration of blood or blood products
having major blood group capabilities.
8. Missing patients – A “high risk” resident who disappears (or elopes) from the VMH or
while temporarily out of the VMH for outpatient treatment or furlough, while a resident of
the VMH. A high-risk resident is one who is “incapacitated because of frailty, or physical
or mental impairment.” NOTE – Because the period of time ‘missing’ and/or
‘categorization of high versus low risk’ may be defined and/or interpreted differently
among STATES, follow the State requirements for reporting and determination as to
whether the event is to be considered Sentinel.
RESIDENT RIGHTS 04-02-013
-8-
C. The Safety Assessment Code (SAC) Matrix scoring process must be applied, as outlined in the
VA State Veterans Homes Patient Safety Handbook, under APPENDIX – The Safety Assessment
Code (SAC).
D. If the Event is rated a SAC score of three (‘3’), the event requires a Root Cause Analysis
(RCA) report.
E. All Sentinel Events require reporting and documentation by the VMH to the Veterans
Administration Medical Center (VAMC) of Jurisdiction.
1. Verbal and written notification:
a. New Jersey Department of Military and Veterans Affairs, Division of Veterans Healthcare Services (DVHS), Division Director
Trenton, New Jersey
Work ……….609-530-6967
Fax………….609-530-6970
Cell………….609-839-9090
b. Department of Veterans Affairs, VA New Jersey Health Care System
C. Denise Coutsouridis, LCSW, ACSW, MSW
State Veterans Home Coordinator
Work………..908-647-0180, ext. 4151
Fax………….908-604-5226
Pager………..973-282-7802
E-Mail………denise.coutsouridis@med.va.gov
c. Delaware VA Medical Center
Adrian Borbst, NP
State Veterans Home Coordinator
Work………..302-633-5330
Fax………….302-633-6381
Evenings, weekends and holidays:
1-800-461-8262, ext. 5330 - Leave Voice Mail Message
ROOT CAUSE ANALYSIS.
A. The goal of a Root Cause Analysis is to find out
RESIDENT RIGHTS 04-02-013
-9-
UNUSUAL INCIDENTS
B. Root Cause Analysis is a tool for identifying prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame.
C. In Root Cause Analysis, basic and contributing causes are discovered in a process similar to diagnosis of disease - with the goal always in mind of preventing recurrence.
D. Root Cause Analysis is:
E. To be thorough, a Root Cause Analysis must include:
F. To be credible, a Root Cause Analysis must:
G. Using the Five Rules of Causation* for Root Cause Analysis (*Adapted from David Marx):
The five rules of causation are designed to improve the RCA process by creating minimum standards for where an investigation and the results should be documented. The rules are created in response to the very real biases we all bring to the investigation process.
Rule 1 - Causal Statements must clearly show the
"cause and effect" relationship.
This is the simplest of the rules. When describing why an event has occurred,
you should show the link between your root cause and the bad outcome, and each
link should be clear to the RCA Team and others. Focus on showing the link from
your root cause to the undesirable patient outcome you are investigating. Even
a statement like "resident was
RESIDENT RIGHTS 04-02-013
-10-
UNUSUAL INCIDENTS
fatigued" is deficient without your description of how and why this led to a slip or mistake . The bottom line: the reader needs to understand your logic in linking your causes to the outcome.
Rule 2 - Negative descriptors (e.g., poorly, inadequate)
are not used in causal statement.
As humans, we try to make each job we have as easy as possible. Unfortunately,
this human tendency works its way into the documentation process. We may
shorten our findings by saying "maintenance manual was poorly
written" when we really have a much more detailed explanation in
our mind. To force clear cause and effect descriptions (and avoid
inflammatory statements), we recommend against the use of any negative
descriptor that is merely the placeholder for a more accurate, clear
description . Even words like "carelessness" and
"complacency" are bad choices because they are broad, negative
judgments that do little to describe the actual conditions or behaviors that
led to the mishap.
Rule 3 - Each human error must have a preceding cause.
Most of our mishaps involve at least one human error. Unfortunately, the
discovery that a human has erred does little to aid the prevention process. You
must investigate to determine WHY the human error occurred. It can be a
system-induced error (e.g., step not included in medical procedure) or an
at-risk behavior (doing task by memory, instead of a checklist). For
every human error in your causal chain, you must have a corresponding cause. It
is the cause of the error, not the error itself, which leads us to productive
prevention strategies.
Rule 4 - Each procedural deviation must have a preceding
cause.
Procedural violations are like errors in that they are not directly manageable.
Instead, it is the cause of the procedural violation that we can manage. If a
clinician is violating a procedure because it is the local norm, we will have
to address the incentives that created the norm. If a technician is missing
steps in a procedure because he is not aware of the formal checklist, work on
education.
Rule
5 - Failure to act is only causal when there was a pre-existing duty to act.
We can all find ways in which our investigated mishap would not have occurred -
but this is not the purpose of causal investigation. Instead, we need to find
out why this mishap occurred in our system as it is designed today. A doctor's
failure to prescribe a medication can only be causal if he was required to
prescribe the medication in the first place. The
RESIDENT RIGHTS 04-02-013
-11-
UNUSUAL INCIDENTS
duty to perform may arise from standards and guidelines for practice, or other duties to provide patient care.
H. Root Cause Analysis Starting Point.
First:
Was this event thought to be the result of: a criminal act; a
purposefully unsafe act related to alcohol or
substance abuse (impaired provider/staff), or events involving alleged or
suspected patient abuse of any kind
(i.e., those situations which are outside the scope of the patient safety
program)?
Second:
RESIDENT RIGHTS 04-02-013
-12-
UNUSUAL INCIDENTS
Yes -- Respond to all Human Factors questions:
I. Root Cause Analysis Concept Definitions for Triggering Questions.
1. Human Factors / Communication: Questions that help assess issues related to communication, flow of information, and availability of information as needed. These questions also reveal the importance of communication in use of equipment and application of policy and procedure, unintended barriers to communication, and the organization’s culture with regard to sharing information.
2. Human Factors / Training: Questions that help assess issues related to routine job training, special training, and continuing education; including the timing of that training. Training issues may concern application of approved procedures, correct use of equipment, or appropriate manipulation of protective barriers. These questions also focus attention on the interfaces between people, workspace, and equipment.
3. Human Factors / Fatigue / Scheduling: Questions that weigh the influence of stress and fatigue that may result from change, scheduling and staffing issues, sleep deprivation, or environmental distractions such as noise. These questions also evaluate relationships to training issues, equipment use, management concern and involvement.
RESIDENT RIGHTS 04-02-013
-13-
UNUSUAL INCIDENTS
4. Environment / Equipment: Questions to help evaluate factors related to use and location of equipment; fire protection and disaster drills; codes, specifications and regulations; the general suitability of the environment; and the possibility of recovery after an error has occurred. These questions show that what appears to be equipment failure may relate to human factor issues, policy and procedure questions, and training needs.
5. Rules / Policies / Procedures: Questions that help assess the existence and ready accessibility of directives including technical information for assessing risk, mechanisms for feedback on key processes, effective interventions developed after previous events, compliance with national policies, the usefulness of and incentives for compliance with codes, standards, and regulations. The qualifications of the facility and employees for the level of care provided; orientation and training for compliance with safety and security measures including handling of hazardous material and emergency preparedness; and the availability of information to all part time, temporary, or voluntary workers and students are also considered.
6. Barriers: Barriers protect people and property from adverse events. Questions assess barrier strength, fault tolerance, function and interaction/relationship to rules / policies / procedures and environment / equipment.
NOTE 1 – The term Sentinel Event as used by the Centers for Medicare and Medicaid Services (CMS) refers to key quality indicator from the RAI/MDS and is NOT considered a part of the VMH Patient Safety Improvement Handbook.
NOTE 2 – Upon issuance of this procedure, unless a fall or medication error receives a SAC score of three (‘3’), it will NOT be considered a Sentinel Event for the purpose of reporting to the VA. Falls and medication errors should be reviewed as part of the VMH’s Quality Improvement program.
UNUSUAL INCIDENT REPORT - CATEGORY "A" and B" GUIDELINES.
A. CATEGORY "A” INCIDENTS ARE:
1. Alleged homicides, suicide, suspicious or accidental death of a resident or staff member in the line of duty.
2. Alleged abuse, rape, neglect, sexual abuse, assault or exploitation of a resident.
3. Major fires or catastrophe that requires the closing of a Unit/Building for more than 24 hours.
4. Injury to a resident that results in loss of life.
RESIDENT RIGHTS 04-02-013
-14-
UNUSUAL INCIDENTS
5. Major operational breakdowns that are three (3) hours or more, e.g. lack of utilities,
threatened job actions, etc.
6. Serious outbreak of disease or illness reportable to the New Jersey Department of
Health and Senior Services.
7. Any incident that has attracted the attention of the media.
8. Injury to a resident, resulting from a faulty medical device.
(Forward copy of the "Final" Incident Reporting Form and written narrative of the investigation to the Division of Veterans Healthcare Services.)
B. CATEGORY "B" INCIDENTS ARE:
1. Injury to a resident that requires hospital admission.
2. Elopement of a resident.
3. Any situation where one or more residents may be considered to be in imminent
danger.
4. Alleged criminal activity by employee/provider/resident if such criminal activity
causes harm or has the potential to impact on residents.
5. Major operational breakdown of less than three (3) hours.
6. Emergency admission of a resident to a Psychiatric facility.
7. Possession of contraband (e.g. alcohol, drugs, weapons).
8. Medication errors that result in the hospitalization of a resident.
9. Shortages of controlled substances that are reportable to the Chief, Enforcement
Bureau , Drug Control Unit, New Jersey Department of Law and Public Safety,
Division of Consumer Affairs.
10. All incidents of theft.
11. Property damage, loss or criminal mischief.
12. Minor fire not requiring the closing of a unit.
13. Injuries to a resident such as those requiring sutures, second/third degree burns,
avulsion of teeth, suspicious bruises and fractures which are treated at the facility.
RESIDENT RIGHTS 04-02-013
-15-
UNUSUAL INCIDENTS
(Maintain the Incident Report Form and written narrative of investigation at the VMH, if completed. All incidents reported to the New Jersey Department of Health and Senior Services or the Office of the Ombudsman are reported in accordance with Category "A" Guidelines.)
QUALITY IMPROVEMENT PROGRAM.
A. The facility Quality Improvement Coordinator will be responsible to:
1. Track all Accident/Injury and Unusual Incident Reports.
2. Develop a plan of correction for identified weaknesses in collaboration with the responsible department head. Assure implementation and follow-up of all plans of correction.
3. Forward Annual Statistical Report of Accidents/Injuries and Unusual Incident Reports to
the Quality Improvement Coordinator for the Division of Veterans Healthcare Services.
The report is due at the end of January of the following year.
Revised: July 1998
Revised: October 2001
Revised: July 2007