What is a sentinel event in nursing home?

A sentinel event in a nursing home is a serious or harmful incident that leads to death or serious physical or psychological injury to a resident. Specific instances of serious physical or psychological injuries include injuries that require medical treatment, hospitalization, or a significant change in the resident's condition.

Examples of sentinel events in nursing homes can include:

- Falls resulting in fractures or head injuries

- Pressure sores or skin ulcers that develop or worsen

- Medication errors that lead to adverse effects or complications

- Infections or communicable diseases that spread within the facility

- Neglect or abuse that leads to physical or emotional harm

- Resident elopement leading to injury or loss

- Improper use of restraints causing injury or discomfort

- Inappropriate care plans that fail to address resident needs

- Failure to provide necessary supervision or assistance

- Lack of infection control protocols resulting in outbreaks or infections

Sentinel events in nursing homes are often preventable and highlight systemic problems or failures in the facility. They require prompt investigation and corrective action to ensure resident safety and prevent future incidents.