The information contained herein further enhances the information provided in Section II of Achieving Substantial Compliance entitled, "Survey Ramifications." If you are placing this information in your manual, it is suggested you insert it at page 41. This information also relates to quality indicators which are included in the manual at page 212 and are further addressed as part of the "Manual Updates."

HCFA has now determined that there are certain "sentinel events" which, if found present in a facility during survey, will likely result in deficiency citation at a high scope and/or severity level. These sentinel events have been initially determined because they fall outside of the expected parameters of occurrence of the surveyor's use of the quality indicators (see Achieving Substantial Compliance, pages 211-214).

Those quality indicators which are considered as the "general" indicators in the survey process are those in which there is a certain expectation of some occurrence. The majority of quality indicators are considered "general" indicators.

HCFA, however, has, for now, identified three quality indicators for which there is no expectation of an occurrence. In these cases, even one occurrence is seen as a probable indication that a serious problem exists. These occurences have been labeled as "Sentinel Events," and if discovered during the course of a survey could most easily result in an automatic citation at a scope and severity indicating substandard quality of care.

Those occurrences which have been identified as "Sentinel Events" are:

If facilities have any of these events occurring, they are advised to seek professional consultation and/or legal advice to insure their documentation and management systems are in order so as to best prevent the possibility of citation.