N.D. Admin. Code 75-03-40-40

Current through Supplement No. 394, October, 2024
Section 75-03-40-40 - Incident and sentinel event reporting

The facility shall have written policy outlining the documentation of incidents and sentinel events that occur while the resident is in placement. Policy must include:

1. Description of an incident as an unplanned occurrence that resulted or could have resulted in injury to people or damage to property, specifically involving the general public, residents, or agency employees.
a. Incidents involving law enforcement, including in the case of a runaway, criminal activity, behavior resulting in harm to others, or restraint injury. An incident also may involve issues, such as outbreak of a serious communicable disease, harassment, violence, and discrimination.
b. Notification must be made to the custodian and parent or guardian immediately or no more than twelve hours.
2. Description of a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury not related to the natural course of a resident's illness or underlying condition, including any process variation for which a reoccurrence would carry a significant chance of a serious adverse outcome.
a. Sentinel events include serious injury or trauma to a resident, attempted suicide by the resident, death of a resident, or inappropriate sexual contact.
b. Notification must be made to the custodian and parent or guardian, and the department immediately or no more than twelve hours.
3. Documentation of an incident or sentinel event must be completed and placed in the resident's record. The report must include:
a. Resident's name, age, and sex;
b. A description of the incident or event;
c. The date, time, and location of the incident or event;
d. The name of each personnel involved;
e. Methods used to address the resident's behavior, including duration of each intervention;
f. Detailed description of the technique or approach engaged with the resident at the time of the incident or event;
g. Results achieved from methods used to address resident behavior; and
h. Injuries received by either the resident or an employee in using physically enforced separation or restraint, how the injuries occurred, and any medical care provided.
4. The facility shall maintain a log of written reports of incidents involving residents.
5. Direct care employees must be given time at the beginning of each shift to be informed of or review incident reports occurring since their last shift.
6. Personnel and residents must be given time to debrief the incident with clinical personnel.

N.D. Admin Code 75-03-40-40

Adopted by Administrative Rules Supplement 374, October 2019, effective 10/1/2019.
Amended by Administrative Rules Supplement 2021-382, October 2021, effective 10/1/2021.
Amended by Administrative Rules Supplement 2024-392, April 2024, effective 4/1/2024.

General Authority: NDCC 50-11-03

Law Implemented: NDCC 50-11-02