Serious Accident/Illness/Death of a Child/Sentinel Event 620-01-110

(Revised 3/20/12 ML #3317)

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Providers must report, to the authorized agent within 24 hours, a death, serious accident, illness or injury requiring medical care to a child while in child care or attributable to child care.

 

Upon receipt of the report, the authorized agent shall:

 

  1. Immediately send a copy of the SFN 383 to the regional office.
  1. This report must be typed, not handwritten, and sent electronically to the regional office. If the regional supervisor is not available, and there is a potential for the report to be a sentinel event, then the authorized agent shall also send the report to the ECS Administrator at the central office.
  1. Complete an SFN 960, Report of Suspected Child Abuse and Neglect if the authorized agent suspects that the incident is a result of child abuse or neglect.

 

  1. Complete an SFN 1269 Child Care Concern Form if the authorized agent suspects that the incident is a result of a licensing violation.

 

  1. Work collaboratively with CPS and law enforcement, if those agencies are involved in the investigation. CPS or law enforcement will take the lead on joint investigations.

 

  1. Staff with regional office to determine when an unannounced review is appropriate.

 

The regional office staff shall:

 

  1. Determine if further investigation is needed. If further investigation is not needed, the information is entered on the Q Drive files. If further investigation is needed, the regional office forwards a copy of the SFN 383 to the central office. The central office will consult with the regional office to provide guidance to the authorized agent.

 

  1. Determine whether incident is a sentinel event:

“Sentinel event” has been defined as “Any unexpected occurrence involving death or serious physical or psychological injury or risk thereof that is not related to the natural course of the individual’s illness or underlying condition. Serious injury specifically includes inappropriate sexual contact.” The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. They signal the need for immediate investigation and response. Sentinel events in child care will include, but may not be limited to:

 

  1. Incidents that involve law enforcement

 

  1. Deaths

 

  1. Injuries that require medical attention and are suspected to be the result of a licensing violation

If the regional supervisor is unsure of whether or not an incident is a sentinel event, the central office should be consulted with.

 

If the incident is determined to be a sentinel event, the regional office shall:

 

  1. Complete SFN 50508 and submit to Risk Management,

 

  1. Immediately send email with “sentinel event” in the subject line to DHS Executive Director, DHS Public Relations, Director of CFS, ECS Administrator, Director of Legal Advisory Unit, DHS Risk Manager, and the Risk Manager at the regional office. The email should contain as much information as you have at the time about the incident.

The central office shall:

 

  1. Provide guidance to regional office and authorized agent in addressing serious incidents.

 

  1. Review Q Drive files periodically.

 

  1. Maintain an electronic file of all the SFN 383 reports submitted to the central office.

 

  1. Report quarterly to the DHS Risk Manager, numbers of reports categorized by type of incident.