Form 6103, End Stage Renal Disease Facility Incident Report

 

Instructions

Updated: 6/2021

 

Purpose

Form 6103 is used to notify Texas Health and Human Services Commission (HHSC) of an incident and the actions taken by the facility.

Procedure

Submit each form separately within ten business days of the incident. Do not submit multiple incidents in one document. Explain how the facility will improve care as a result of the incident. Complete the entire form with all requested attachments so that HHSC may review the incident without requiring additional information or documents.

Transmittal

Submit each completed form by one of the following (email, fax or mail):

Email: cii.hcq@hhsc.state.tx.us
Fax: 1-833-709-5735 or 512-206-3985
Mail: Texas Health and Human Services Commission
Complaint and Incident Intake
P.O. Box 149030, Mail Code E-249
Austin, TX 78714-9030

Detailed Instructions

Print or type the information and provide as much information as possible. Use the facility name and license number as listed on your license.

Reportable Incident – Check the appropriate box from the following:

• Death of Patient – This includes deaths that occur in the facility, at home or in a hospital.
• Hospital Transfer – Any ambulance transport from the dialysis facility to a hospital due to the patient’s emergent medical condition. This includes ambulance transports after a 911 call whether or not the lights are flashing and/or the siren is on as the ambulance leaves the dialysis facility or parking lot.
• Hepatitis B Conversion – Patient – Conversion of patient to hepatitis B surface antigen (HbsAg) positive. Submit a report with lab results for all patients in the facility with their hepatitis status, antibody status and vaccination status.
• Hepatitis B Conversion – Staff – Conversion of staff to hepatitis B surface antigen (HbsAg) positive. Submit a report with lab results for all staff in the facility with their hepatitis status, antibody status and vaccination status.
• Involuntary Transfer or Discharge of Patient
• Fire in Facility – Submit the report from the fire department.

Date of Report – Enter the report date.

Date of Incident – Enter the date of the incident.

Time of Incident – Enter the time of the incident and check A.M. or P.M.

Date of Last Dialysis Treatment – Enter the date of the last dialysis treatment.

Facility Name – Enter the name of the facility.

Facility License No. – Enter the facility license number.

Facility Provider No. (CCN) – Enter the facility provider number, which is the Medicare six-digit number.

Facility Address – Enter the street address, city, state, ZIP code.

Facility Area Code and Phone No. – Enter the area code and telephone number.

Reporter Name and Title – Enter the contact person and title that the surveyor will ask for should a follow-up telephone call be needed.

Primary Area Code and Phone No. and Secondary Area Code and Phone No. – Enter the area code and telephone numbers.

Email – Enter the email address.

Patient Name – If the incident involves a patient, enter the first, middle and last name.

Date of Birth – Enter the patient’s date of birth.

Date Started Dialysis – Enter the date the patient started dialysis.

Date Admitted to Current Facility – Enter the date the patient was admitted to current facility.

Diagnoses – Enter all diagnoses.

Level of Supervision – Enter the level of supervision.

Does the patient have a history of similar incidents? – Check Yes or No. If yes, explain.

Does the patient receive services from another facility? – Check Yes or No.

If yes, where? – Check the box for home health, hospice, assisted living or other. If other, enter the other facility.

Facility Name – Enter the name of the facility.

Area Code and Phone No. – Enter the facility area code and phone number.

Address – Enter street, city, state and ZIP code.

Service Type – Check the box for Hemodialysis (HD) In-Center, Peritoneal Dialysis (PD) or Home HD.

Access Type – Check the box for graft, fistula, central catheter or PD.

Current Condition – Check the box for disposition of resident, deceased or in hospital (provide name).

Treatment Information – Check the services type (HD In-Center, PD or Home HD) and access type (graft, fistula, central catheter or PD). Complete the charts based on the examples below. Attach copies of the last three treatment sheets. If the patient is deceased, also include the mortality review of the patient.

Current Dry Weight – Enter the Kg.

Total Heparin Dose – Enter the units.

Reuse No. – Enter the reuse number.

Chart for Pulse, Blood Pressure and Weight – Enter the date and pre and post for pulse, blood pressure and weight.
Example:

	Pulse		Blood Pressure		Weight
Date	Pre	Post	Pre	Post	Pre	Post
2/14	80	74	130/74	120/65	84 kg.	80 kg.

Chart for Hct. or Hgb., Kt/V or URR and Potassium – Enter the date and result for each.
Example:

Hct. or Hgb.		Kt/V or URR		Potassium
Date	Result	Date	Result	Date	Result
2/9	33.1	2/1	67%	2/1	4.5

 

Alleged Perpetrator Name and Title – Enter the alleged perpetrator’s name and title. List only alleged perpetrators who are not patients. Alleged perpetrators who are patients should be listed in the “Patient” section. If the alleged perpetrator is neither a patient nor a staff member, indicate the relationship of this person to the patient (example: friend, family member, etc.).

Social Security No. – Enter the alleged perpetrator’s Social Security number.

License No. – Enter the alleged perpetrator’s license number.

Area Code and Phone No. – Enter the alleged perpetrator’s area code and phone number.

Alleged Perpetrator Address – Enter the alleged perpetrator’s street address, city, state and ZIP

Summary

When did the incident occur? – Enter the date.

On what shift? – Check the box for day, evening or night.

Provide a brief summary – Enter what happened, who was involved (e.g., RN, LVN, PCT, MD, other), and the action taken at the time of the incident. Example: The treatment was started without incident. About two hours after the treatment began, the PCT noted that the patient's blood pressure dropped from 130 systolic to 90 systolic. The nurse assessed the patient and found the patient was asymptomatic. The blood pressure was retaken, and it was 92 systolic. The patient was placed in Trendelenburg position, and the blood pressure was retaken after 15 minutes. The patient began experiencing dizziness, and the blood pressure was now 89 systolic. The nurse administered 200 cc normal saline. After 15 minutes the blood pressure dropped to 80 systolic, and the physician was notified. 911 was called and the patient was transferred to the hospital for evaluation. She remained there overnight and was discharged within 48 hours.

Did the patient sustain any injuries? – Check Yes or No and if yes, provide an explanation of the injuries and treatment provided.  

Were X-rays performed? – Check Yes or No and if yes, provide X-ray results.  

Hospital Discharge Date (Hospital Transfers Only) – Enter the date the patient was discharged.

Hospital Outcome and Diagnosis (Hospital Transfers Only) – Enter the patient outcome result from the hospital and the patient diagnosis upon discharge.

Provide a narrative report of the investigation – Explain how you handled the incident and what actions you will take to reduce the potential for similar incidents in the future. Example: The investigation concluded the patient's record was evaluated, and it was noted that the patient had been experiencing hypotension (down to 95 systolic) for the past two weeks during the dialysis treatment. The dietitian had identified about three weeks ago that the patient had gained weight following the Christmas holidays. The physician had not adjusted the patient's dry weight. An interdisciplinary team met to discuss the change in the patient's condition. The dry weight was increased by 3 kgs. and a plan was discussed to assist the patient in weight loss. A representative of the interdisciplinary team met with the patient after her return to the clinic to discuss the change in the patient care plan. The patient agreed with the dietary plan and will meet with the dietitian bi-monthly to evaluate her progress. The patient's fluid status will be evaluated monthly or as required according to the dietitian's report. Staffing on 09/10/19 met state requirements. The registered nurse assessed and documented the assessment at the time of the incident. QA discussed failure of staff to identify and report the patient's hypotension for two weeks. Educated staff and physicians. This QA indicator will be done ongoing on a monthly basis.

Actions to be taken as a result of this incident – Check all boxes that apply.

Patient Transfer

Name of Facility – Enter the name of the facility if the patient was transferred to another facility.

Date of Transfer – Enter the date.

Address – Enter the street address, city, state and ZIP code.

Also Include – If the patient is transferred to another facility, also include the following: Plan of care and reassessment of the patient's plan of care, physician’s orders, evidence of interventions with the patient and/or caregiver (i.e., progress notes), coordination with Network 14, copies of policies/procedures for involuntary transfer of a patient and copies of letters to patient.

Printed Name, Signature and Date – The supervising authority signs, prints his/her name and enters the date. Then, email, fax or mail the completed incident form to the number or address provided above under Transmittal.