Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.
As managers and supervisors gain experience in doing RCAs, more people in the facility can be trained to
serve as team facilitators. The facilitator is responsible for assembling and managing the team, guiding the
analysis, documenting findings and reporting to the appropriate persons.
The number of team members depends on the scope of the investigation. Individuals selected to serve as
team members must be familiar with the processes and systems associated with the event. People who have
personal knowledge of what actually happened should be included as team members or given an opportunity
to contribute to the investigation through interviews.
Helpful Tips:
o Team members should be selected for their ability to discuss and review what happened
during the event in an objective and unbiased manner. In some situations, staff members
personally involved in the event are the best people to serve as team members. In other
situations, staff members not personally involved in the event are the best people to serve as
team members with the people personally involved asked to share their experience during
interviews. This may be appropriate if the people directly involved in the event are dealing
with emotions and are not able to be objective. However, if this is the case, it is a good idea to
provide those staff persons directly involved with counseling and support so that they are able
to participate in the RCA process. Participating in the RCA process and hearing other’s
objective viewpoints can help them to deal with the situation in a positive manner.
o Keep the number of management or supervisory level individuals on the team to a minimum.
Staff members may be inhibited from speaking up or being completely candid during
discussions about what happened if their direct supervisor is in the room. If this is not possible,
the facilitator should explain the need for members to be free to discuss the process honestly,
as it is actually carried out in the facility.
o Make it clear to everyone involved that the RCA process is confidential. This reassurance helps
people feel safer discussing the process and system breakdowns that may have caused an
inadvertent mistake.
Step 3: Describe what happened
At the first meeting of the team, a time line of the event under review is created. The preliminary information
gathered in step 1 is shared with the team and other details about the event are elicited from team
members. If the people personally involved in the event are not part of the team, their comments about what
happened are shared with team members. All of this information is used to create a time line of the event –
the sequence of steps leading up to the harmful event.
Below is a time line for a situation involving a resident that suffered a serious injury during his transfer from a
wheelchair back to his bed. This tall and larger man (300-pound) was placed in a Hoyer lift and elevated into
the air above his wheelchair. As the CNAs turned the lift toward the bed it began to sink because the lift arm
couldn't handle the resident’s weight. In an attempt to complete the transfer before the patient was below
the level of the bed, the CNAs swung the lift quickly toward the bed. The lift tilted dangerously to the side
and the legs started to move together, narrowing the base of support. The resident dropped to the ground
and the lift fell on top of him.