Sending the Signal: Notifications Activate the Organization’s Response to an Incident

When an incident occurs in aging services, the very first steps taken—including identifying the incident, caring for the people affected, making an initial determination of severity, and conducting internal and external notifications—are critical. Regardless of how organizations define adverse events, occurrences, or other types of incidents, the same key identification and follow-up steps should be followed to ensure continuity of care, regulatory compliance, and the trust of all involved parties. But incident management plans often do not adequately account for these steps and the myriad challenges that can arise in both routine and unusual circumstances. 

For example, failure to promptly identify that an incident has happened and notify appropriate people, internally and externally, may exacerbate harm to individuals or damage to objects or property; lead to injury of others if hazards are not quickly addressed; and hinder fact collection, potentially impeding investigation and analysis or abrogating legal protections. 

The hypothetical scenarios at Box 1 illustrate the harm that can result when these seemingly simple tasks are missed or inadequately performed.

When these errors in process occur, residents, families, and the surrounding community may view the resulting problems as stemming from lack of care about persons served and an inability to fulfill duty-of-care obligations. Indeed, the COVID-19 pandemic has illustrated the importance of timely recognition and communication of these incidents—not only in fulfilling regulatory obligations, but especially in establishing and maintaining a culture of trust and transparency among staff, residents, families, and the community. By contrast, the ability to quickly identify an incident, make an initial determination of its severity, conduct timely notifications, and implement the appropriate response shows the level of importance the organization places on the safety of all persons served—those who provide care and services, and visitors. 

This article discusses the importance of internal and external notifications and best practices to help organizations mobilize a response to an incident in a timely fashion. 

Immediate Response and Notifications in Context

Immediate identification, severity determination, response, and notifications are time-sensitive and critical because they set everything else in motion. Figure 1 illustrates the many elements of postincident response in three phases. Phase I includes immediate identification, severity determination, response, and notifications.   

Notification of Supervisor

The individual who witnesses or discovers the incident should attend to the resident to the extent their licensure and training allow, make the initial notification to a supervisor, and later contribute to the internal incident report. Giving frontline staff responsibility and accountability for resident safety is empowering.¹ All employees, nonemployed professional staff, volunteers, visitors, and residents should be encouraged to report incidents and near misses. For organizations with multiple locations, organizational notification and reporting responsibilities extend to off-site facilities and treatment locations (eg, home health agencies, hospices).

Internal and External Notification

Supervisors and frontline managers must decide the appropriate levels of internal and external notification. Factors that may affect this determination include the nature of an incident, the severity including the degree of actual or potential harm, the potential for other negative outcomes, and external requirements. Within the organization, notification about an incident should go up the chain of command. External notification means providing notification to appropriate parties about the incident, including emergency services personnel, primary care physicians, police or other indicated authorities, families, and regulatory agencies as needed or required.

The internal and external notification process differs from completing an incident report and from ongoing communication. Notifications, whether conducted in person or by phone, email, or automated process, inform appropriate individuals that an incident has occurred. They also provide basic facts about the incident to drive ongoing response and about the status and well-being of people involved in the incident. By contrast, incident reports collect, record, and communicate information about the incident, and ongoing communication provides continual updates to vested parties throughout the postincident process.

The organization should ensure timely notifications and document the times notifications are made. In addition, when notifying or reporting to families or other external entities, explaining which initial steps for well-being and safety were taken can convey a strong sense of reassurance and transparency about the incident, helping to protect trust. Anticipating questions and preparing accurate answers for the people being notified is another important part of the process, which helps to convey a sense of reassurance and confidence.

Immediate Internal Notifications

Internal notifications are those that occur within an organization as part of an organization’s postincident response process. Based on the severity of the incident, internal notifications should be communicated to the appropriate positions to facilitate decision-making and action for postincident response. 

Failures in immediate internal notification can contribute to escalation of an incident and resident harm. For instance, after a nursing home resident who was admitted after a psychiatric hospitalization attacked his roommate, the US Department of Health and Human Services’ Departmental Appeals Board (DAB) upheld nearly $700,000 in penalties against the facility.² On a previous occasion, staff had discovered bruising on the roommate’s shoulders and scratches on the resident’s neck but could not determine the cause. Two weeks later, a certified nursing assistant (CNA) found the resident by the roommate’s bed, pulling on the privacy curtain and bed linens. When the CNA tried to persuade the resident to return to his bed, the resident scratched the ’an’s neck. The CNA left the residents alone in the room together, then told a licensed practical nurse (LPN) at the nurse’s station about the attack. The LPN told the CNA to tell his supervisor. The CNA found his supervisor, another LPN, smoking outside. While they both smoked on the porch, the LPN at the nurse’s station heard yelling and went to the residents’ room. She saw the resident leaning over the roommate, biting his neck and shoulders.

The supervising LPN completed an incident and investigation report, but the facility did not report this event to the state agency, reasoning that it did not need to do so because the resident was not capable of intentional abuse. A complaint survey cited 8 deficiencies at the immediate-jeopardy level related to the alleged attacks.

DAB upheld the citations and penalties, citing several reasons, including notification failures. For example, DAB noted that the supervising LPN left her post without telling others where she would be. The CNA left the resident and roommate alone together for a disputed but substantial time period while he smoked on the porch with his supervisor, and the LPN at the nurse’s station did not check on the residents or send anyone else to do so. The facility also entirely failed to report the incident to the state agency.²

Many provider organizations are implementing internal electronic incident reporting systems that combine the submission of incident reports with automatic electronic notification of internal designees (eg, director of nursing, administrator, risk manager). However, the notification process is separate from the incident reporting process. As illustrated in the example at the beginning of this article, a failure in electronic incident reporting can cause a failure in notification if the organization does not treat these steps as separate and have redundancies or backups in place, potentially including nonelectronic methods.

Immediate External Notifications

Certain internal and external notifications often occur simultaneously after an incident. Procedures or protocols should identify who may conduct each type of external notification, and these staff members should be trained in conducting such notifications.

Laws, insuring agreements, or other requirements may mandate reporting of certain circumstances, such as the following:

• Suspected elder abuse

• Suspected crimes

• State adverse event reporting requirements

• Medical device reporting

• Public health surveillance (eg, infectious disease outbreaks)

• Worker illness and injury reporting

• Required reporting to accreditors

• Required reporting to insurers

• Required reporting to licensing boards or the National

• Practitioner Data Bank

Not all of these circumstances need to be reported immediately and not all apply to aging services organizations themselves—for example, some may apply only to physicians or licensed health care personnel. However, aging services organizations should determine which reporting requirements apply to them, their medical directors, or their staff and the required timeframes for reporting. The organization should also determine timeframes for permissive reporting (eg, to a patient safety organization).

Contacting a family or emergency contact person with basic and verified facts about the incident and communicating which initial actions have been taken can create a sense of confidence that the safety and well-being of persons involved in the incident are paramount. Conversely, if information turns out to be nonfactual or if important questions and concerns about a loved one or patient go unaddressed, it can lead to misconceptions about the organization, its processes, and its motivations.

The organization’s policies, guidelines, and training must consider many factors when establishing expectations and mapping the organization’s communication pathways for internal and external notification. Staff training and practice should provide guidance for making these decisions, often made difficult by the nature of what must be communicated. It is important to include back-up communication pathways and necessary redundancy. Notification should also include closed-loop communication, such as verification of receipt.

It is also imperative to account for federal, state, and local regulatory requirements and laws that address mandatory reporting. External notification requirements can drive not only what must be reported and when but also earlier steps in the process, such as the timing and content of initial notifications, decision-making, and analytical and investigatory steps.  

Conclusion

Effective and timely notification processes help to ensure that organizational response to an incident matches the severity of the incident, places appropriate persons on notice that the incident occurred, and mobilizes resources for response to ever-changing postincident circumstances. It can also convey a degree of competence about the organization’s care and services, helping to guard against suspicions about motives and the undermining of trust. Upon completion of necessary measures to protect the well-being and safety for those involved and making appropriate notifications, the assigned staff can then focus efforts on an initial investigation.

To read more practical aging services risk management suggestions to help your organization improve identification and notification of incidents, download “Incident Identification and Notifications in Aging Services” at ecri.org/incidentnotifications.3 This white paper includes additional guidance on incident identification and notification. Additional details on event investigations are available with the free white paper “Incident Investigation in Aging Services,” available at ecri.org/landing-incident-investigation-aging-services/. 

References

1. Sankaranarayanan K, Matarelli SA, Parkar H, Haltem MA. From blame to fair and just culture: a hospital in the Middle East shifts its paradigm. Patient Saf Qual Healthcare. August 12, 2013. Accessed May 13, 2020. https://www.psqh.com/analysis/from-blame-to-fair-and-just-culture-a-hospital-in-the-middle-east-shifts-its-paradigm/ 

2. Department of Health and Human Services, Departmental Appeals Board. The Bridge at Rockwood, Decision No. 2954. July 15, 2019. Accessed May 13, 2020. https://www.hhs.govhttps://s3.amazonaws.com/HMP/hmp_ln/imported/board-dab-2954.pdf

3. ECRI. Incident investigation in aging services: a systems thinking approach. Contin Care Risk Manage. April 2020. Accessed May 13, 2020. https://www.ecri.org/incidentnotifications