Code of Federal Regulations Title 38. Pensions, Bonuses, and Veterans' Relief § 38.51.430 Quality of care

(1) Definition. A “sentinel event” is defined in § 51.120(a)(1).

(2) Duty to report sentinel events. The State home must comply with the duties to report sentinel events as set forth in § 51.120(a)(3), except that the duty to report applies only to a sentinel event that occurs while the participant is under the care of the State home, including while in State home-provided transportation.

(3) Review and prevention of sentinel events. The State home must establish a mechanism to review and analyze a sentinel event resulting in a written report to be submitted to the VA Medical Center of jurisdiction no later than 10 working days after the event. The purpose of the review and analysis of a sentinel event is to prevent future injuries to participants, visitors, and personnel.

(1) No diminution in activities of daily living. A participant's abilities in activities of daily living do not diminish unless the circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the participant's ability to

(2) Appropriate treatment and services given. A participant is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (b)(1) of this section.

(3) Necessary services provided to participant unable to carry out activities of daily living. A participant who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, hydration, grooming, personal and oral hygiene, mobility, and bladder and bowel elimination.