{"ref":"NC-HSP-QA-02","title":"Incidents, Adverse Events and Reports to the Division","category":"Quality","summary":"Sets out what staff do when something goes wrong: make the patient safe, report to a supervisor at once and on Form NC-HSP-QA-02-A by the end of the shift, and make every outside report on time (a death from injury, accident or other possible unnatural causes to the Department; allegations against unlicensed staff to the Health Care Personnel Registry within 24 hours; abuse and neglect to the county department of social services; suspected crimes against residents of long-term care facilities within 2 or 24 hours). It then sets out investigation, analysis and learning through the QAPI program.","inShort":["Make the patient safe first and call 911 in an emergency.","Tell the nurse on call and your supervisor at once. For anything serious, call the Administrator right away.","Chart only the facts in the record, and complete Form NC-HSP-QA-02-A before the end of your shift.","Allegations against unlicensed staff go to Health Care Personnel Investigations within 24 hours. A suspected crime against a nursing facility resident is reported within 2 hours if there is serious injury, otherwise within 24 hours.","Any death from an injury, accident or other possible unnatural cause is reported to the Department.","No one is disciplined for reporting an incident in good faith."],"primaryCitation":"10A NCAC 13K .1108(7)","citations":["10A NCAC 13K .1108(7)","10A NCAC 13O .0102","G.S. 131E-256(g)","G.S. 108A-102","G.S. 7B-301"],"federalCitations":["42 CFR §418.58(a)(2), (c)(2)","42 CFR §418.52(b)(4)","42 CFR §418.112(c)(8)","42 CFR §418.110(p)","42 U.S.C. §1320b-25"],"surveyorAsks":["Show me your incident log for the last quarter and how incidents feed into QAPI.","Has any patient died from an injury, accident or other possible unnatural cause? How and when did you notify the Department?"],"forms":[{"ref":"NC-HSP-QA-02-A","title":"Incident and Adverse Event Report"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13K .1108(7))","5. First Response","6. Reports Outside the Agency","6.1 Posting for staff serving long-term care residents","7. Review and Investigation","8. Learning Through the QAPI Program","9. No Blame for Reporting","10. Responsibilities","11. Records and Compliance Monitoring","12. Staff Training","13. References","14. Related Policies and Forms","15. Approval","16. Revision History"],"version":"1.0","sample":false,"pack":"nc-hospice","state":"North Carolina","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}