Current through 2024-38, September 18, 2024
3.1
Notification by next business day. The healthcare facility must notify
the SET of a sentinel event (Section 1.22) by the next business day after the
event occurred or the next business day after the facility discovers that the
event occurred. The notification must include but is not limited to the date
and time of notification, the name of the health care facility, the type of
sentinel event, and the date and time the sentinel event occurred. See 22
M.R.S.A. §8753(1).
3.2
Notification Procedure. Immediately upon discovery of a sentinel event,
the facility must act in accordance with its notification procedures as
required by Section 2.1 of these rules.
3.2.1
Notification of the discovery of a sentinel event must not be delayed secondary
to internal deliberations or pending autopsy or medical examiner
results.
3.2.2 Within 1 business
day of the discovery of a sentinel event, the healthcare facility must send the
department-approved sentinel event notification form to the SET by facsimile or
encrypted e-mail.
3.3
Situational Notification Considerations.
3.3.1
Inter-facility Transfer
Notification. A sending facility is required to submit to the SET
notification regarding a sentinel event when the transfer to another facility
is unrelated to the natural course of the patient's illness or underlying
condition; or unrelated to the proper treatment of that illness or underlying
condition in its healthcare facility.
3.3.2
Discharge Follow-up
Notification.
3.3.2.1 A facility is
required to submit to the SET notification by the next business day after the
event occurred or the next business day after the facility discovers that the
event occurred regarding a sentinel event involving a patient with amajor
permanent loss of function that is present at the time of discharge that is
unrelated to the natural course of the patient's illness or underlying
condition or proper treatment of that illness or underlying condition in a
health care facility.
3.3.2.1.1 If within 14
days of discharge from a health care facility, evidence is discovered that the
major loss of function was not permanent, the facility must submit the
department-approved Functional Evidence form with supporting documentation to
the SET, and the health care facility is not required to submit the root cause
analysis (RCA) report required in Section 4 of these rules. See 22 M.R.S.A.
§8752(4-A)(B).
3.3.2.2 A facility is required to submit to
the SET notification by the next business day after the event occurred or the
next business day after the facility discovers that the event occurred when a
sentinel event involving a death or major permanent loss of function occurs
within 48 hours of treatment or procedure at a health care facility that is
unrelated to the natural course of the patient's illness or underlying
condition; or unrelated to the proper treatment of that illness or underlying
condition in a health care facility.
3.3.2.3 A facility is required to submit to
the SET notification by the next business day after the event occurred or the
next business day after the facility discovers that the event occurred when the
suicide of a patient occurs within 48 hours of discharge from a health care
facility.
3.3.3
Notification of sexual assault. If
one or
more of the following criteria is met, the facility is required to
submit sentinel event notification regarding a sexual assault that occurred
within or on the grounds of a health care facility:
3.3.3.1 Any staff-witnessed sexual
assault;
3.3.3.2 Sufficient
clinical evidence obtained by the health care facility to support allegations
of sexual assault; or
3.3.3.3
Admission by the perpetrator of a sexual assault that occurred on the
premises.
3.3.4
Notification of serious event. A facility is required to submit sentinel
event notification regarding a serious event lasting more than seven days or
still present at the time of discharge from a facility.
3.4
SET Case Review. Upon
receipt of a notification or report of a sentinel event, the SET completes an
initial review and may take other action that it determines to be appropriate
pursuant to these rules. The facility must comply with the following
requirements for the SET case review:
3.4.1
Provide a copy of the patient's medical record.
3.4.2 Provide a timeline of the
event.
3.4.3 Present details of the
event.
3.4.4 Schedule SET
conference with the CEO or Administrator.
3.4.5 Schedule SET de-briefing regarding the
findings with the facility.
3.5
Immediate Jeopardy. The
division personnel responsible for sentinel event oversight shall report to the
division's licensing section only incidences of immediate jeopardy and each
condition of participation in the federal Medicare program related to the
immediate jeopardy for which the provider is out of
compliance.
