Form 6103, End Stage Renal Disease Facility Incident Report

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Documents

Effective Date: 10/2024

Instructions

Updated: 10/2023

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 the required time frame of the incident:

  • Within one business day: Any fire incident that causes injury to a person.
  • Within 10 working days:
    • Death of a dialysis patient that occurs in the facility, at home or in a hospital
    • Hospital transfers
    • Conversion of staff or a patient to hepatitis B surface antigen (HbsAg) positive
    • Involuntary transfer or discharge of a patient
    • A fire in the facility

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 HHSC can review the incident without requiring additional information or documents.

Transmittal

Submit each completed form by one of the following:

Email: CII.HCQ@hhs.texas.gov
Fax: 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:

  • Facility fire that causes an injury - Fire that causes an injury
  • 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 because of the patient’s medical condition. This includes emergent and non-emergent hospital transfers via ambulance whether or not the lights are flashing, the siren is on or both 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 AM or PM.

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 phone number.

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

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

Code Status: Select the patient’s code status as Full, DNR or Other.

Level of Supervision – Enter the patient’s level of supervision.

Does the patient have a history of similar incidents? – Check Yes or No. If yes explain in detail. Include dates the previous similar incidents took place.

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.

Does the patient receive in-center dialysis services onsite at the nursing home facility? - Check Yes or No.

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, returned to previous modality, deceased or in hospital. Provide name of hospital.

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 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:

 PulseBlood PressureWeight
DatePrePostPrePostPrePost
2/148074130/74120/6584 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 URRPotassium
DateResultDateResultDateResult
2/933.12/167%2/14.5

 

Alleged Perpetrator Name and Title – Enter the alleged perpetrator’s name and title. List only alleged perpetrators who are not patients. List alleged perpetrators who are patients in the Patient section. If the alleged perpetrator is not a patient or a staff member, indicate the relationship of this person to the patient, such as friend or family member.

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 Code.

Witness Name – Enter the name of the witness. Witnesses can include other patients, staff members, family members or friends.

Title- Enter the title of the witness if the witness is a staff member.

Area Code and Phone No. – Enter the phone number of the witness.

Summary

Date the incident occurred. – Enter the date.

On what shift did the incident occur? – Check day, evening or night.

Provide a summary – Enter what happened, who was involved such as an RN, LVN, PCT, MD or other and the action taken at the time of the incident. Example: The treatment 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, 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. If yes, provide an explanation of the injuries and treatment provided. 

Were diagnostic tests performed such as X-ray, CT scan, MRI, ultrasound, PET scan, blood work or other? – Check Yes or No. If yes provide diagnostic tests 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. It was noted that the patient had been experiencing hypotension, down to 95 systolic, for the past two weeks during the dialysis treatment. About three weeks ago the dietitian had identified 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.

Involuntary Transfer or Discharge of a Patient – Select the type of discharge.

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 include the following: Plan of care and reassessment of the patient's plan of care, physician’s orders, evidence of interventions with the patient, caregiver or both, such as progress notes, coordination with Network 14, copies of policies or procedures for involuntary transfer of a patient and copies of letters to patient.

Printed Name, Signature and Date – The supervising authority signs, prints their name and enters the date. Email, fax or mail the completed incident form to the number or address under Transmittal.