The Centers for Medicare & Medicaid Services (CMS) defines an adverse event as “an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof, which includes near misses,” according to the surveyor guidance at F867 (QAPI/QAA Improvement Activities) in Appendix PP of the State Operations Manual. Potentially preventable adverse events can involve medication issues (e.g., change in mental status/delirium related to use; ketoacidosis related to use of antidiabetic medication; etc.), resident care issues (e.g., falls, abrasions/skin tears, or other trauma related to care; elopement without injury of a cognitively impaired resident; etc.), or infections (e.g., respiratory infections, such as pneumonia or influenza; urinary tract infections, including catheter-associated and non-catheter-associated UTIs; etc.).
CMS makes identifying, reporting, tracking, investigating, analyzing, and preventing adverse events a priority of every facility’s quality assessment and assurance (QAA) committee and quality assurance and performance improvement (QAPI) program under F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt) and F866 (QAPI/QAA Data Collection and Monitoring) in addition to F867.
However, the ability to conduct effective investigations into adverse events is crucial from a risk perspective as well to reduce the incidence and impact of negligence lawsuits related to sentinel events (i.e., the most severe form of adverse events), which the Joint Commission defines as resident safety events that cause death, permanent harm, or severe temporary harm, says Laura Ginett, a healthcare attorney and partner at Hall, Prangle, and Schoonveld LLC who will be co-presenting the session Anatomy of an MDS/Care Planning Lawsuit at the 2020 AAPACN Conference in April.
Ginett offers directors of nursing services (DNSs) the following suggestions for optimizing investigations to limit risk: