10A NCAC 70K .0210       CRITICAL INCIDENTS AND CRITICAL INCIDENT REPORTS

(a)  A maternity home shall have written policies and procedures for handling and reporting critical incidents.

(b)  The maternity home shall have and follow policies and procedures for handling any suspected incidents of abuse or neglect of a resident involving staff, subcontractors, volunteers or interns in a facility supervised by the maternity home.  The policies and procedures shall include:

(1)           a provision for reporting any  suspicions of abuse or neglect to the appropriate county department of social services for investigation;

(2)           a provision for recording any suspected incident of abuse or neglect and for promptly reporting it to the executive director or to the governing body; 

(3)           a provision for notifying the parents, guardian, or legal custodian, if applicable;

(4)           a provision for preventing a recurrence of the alleged incident pending the investigative assessment;

(5)           a policy concerning personnel action to be taken when the incident involves a staff member, subcontractor, volunteer or intern;

(6)           a provision for submitting a critical incident report to the licensing authority within 72 hours of the incident being accepted for an investigative assessment by a county department of social services; and

(7)           a provision for submitting written notification to the licensing authority within 72 hours of the case decision by the county department of social services conducting the investigative assessment.

(c)  Critical incident reports shall be submitted to the licensing authority by the executive director or his/her designee on a form developed by the licensing authority within 72 hours of the critical incident.  Critical incidents include the following of   a resident in placement:

(1)           a death of a resident;

(2)           reports of abuse and neglect;

(3)           admission to a hospital as a result of injury or serious medical condition;

(4)           suicide attempt;

(5)           runaway lasting more than 24 hours; and

(6)           arrest for violations of state, municipal, county or federal laws.

(d)  Documentation of the critical incident shall include:

(1)           name of resident or residents involved;

(2)           date and time of incident;

(3)           brief description of incident;

(4)           action taken by staff;

(5)           need for medical attention;

(6)           name of staff involved and person completing the report;

(7)           name of resident's parents, guardian or legal custodian, if applicable, notified and date and time of notification; and

(8)           approval of supervisory or administrative staff reviewing the report.

(e)  When there is a death of a resident in placement the executive director or his/her designee shall notify the parents, guardian, or legal custodian, if applicable, and the licensing authority with 72 hours.

(f)  Critical incident reports shall be maintained in a manner consistent with the agency's risk management policies that include clinical decisions and activities undertaken to identify, evaluate and reduce the risk of injury to residents, staff and visitors and reduce the risk of loss to the agency and shall be made available to the licensing authority upon request..

History Note:        Authority G.S. 131D-1; 143B-153;

Eff. October 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. April 5, 2016.