CMS SOM App. N, Tag N0209

occurrence was reported to both the State Medicaid agency and the State designated

Protection and Advocacy system, including the name of the person to whom the

incident was reported. A copy of the report must be maintained in the resident’s

record, as well as in the incident and accident report logs kept by the facility.

Interpretive Guidelines§ 483.374(b)(3)

Review the facility policies to determine:

a. That “serious occurrence” is defined in a manner that is consistent with this

regulation;

b. That the policies include procedures that staff must follow in reporting serious

occurrences;

c. If the facility designates who should report and follow up on serious occurrences;

d. If the policy addresses investigation of injuries of unknown origins

Interview staff to determine what method the facility uses to report serious occurrences.

Ensure that the staff is able to differentiate between what should and should not be

reported.

During the onsite survey, request a list of all the serious occurrences reported to the state

Medicaid agency and the Protection and Advocacy organization within the past year.

Observe for patterns of injury that may be associated with action or inaction on the part

of the facility.