1. State Veterans Homes Event Reporting Meeting with Quality Assurance Committee of National Association of State Veterans Homes (NASVH) Valarie Delanko and Kristi Howard July 2015

2. VETERANS HEALTH ADMINISTRATION Discussion Topics Sentinel Events Sentinel Events Required to Report Reportable Events Reportable Events Requested to Report

3. VETERANS HEALTH ADMINISTRATION Sentinel Events State Veterans Homes must report sentinel events to the Director, VA Medical Center of Jurisdiction as outlined in 38 CFR Part 51.120 and 38 CFR 52.120.

4. VETERANS HEALTH ADMINISTRATION Sentinel Events Required to Report 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 (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. 38 CFR Part 51.120 and 38 CFR 52.120

5. VETERANS HEALTH ADMINISTRATION Reportable Events State Veterans Homes are requested to 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 has requested 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.

6. VETERANS HEALTH ADMINISTRATION Reportable Events Requested to Report 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. Information regarding the SVH that appears in local or national media. Falls with significant injury which require the resident to be sent out of the facility for medical intervention. NOTE: Falls that are unlikely to result in major or permanent loss of function, but where significant injury occurs (requiring the resident to be sent out of the facility for medical intervention) are considered adverse events for the purposes of section.

7. VETERANS HEALTH ADMINISTRATION Questions? Contacts: Kristi Howard GEC Policy – 202-461-7258 Valarie Delanko GEC Operations – 814-860-2201