A hospital shall develop and implement written procedures to identify, report, and investigate sentinel events. The procedures shall include:(1) a description of the process by which a staff member reports a sentinel event, including a requirement that a sentinel event be reported by a staff member within at least one hour after a staff member becomes aware of the incident;(2) a requirement that, within 24 hours of a sentinel event being reported, the administrator designate a committee to investigate the sentinel event that includes a physician, a Registered Nurse (RN), and any other staff members determined appropriate by the administrator; and(3) a requirement that, within 45 days of the sentinel event being reported, the committee will determine and document:(A) the cause or causes of the sentinel event;(B) whether the cause or causes are random or a pattern of error in the hospital's processes or systems;(C) any improvements to the hospital's processes or systems that may reduce the occurrence of similar incidents in the future;(D) how such improvements will be implemented including a timeline for implementation;(E) the staff members responsible for such implementation; and(F) a method to determine whether the improvements identified were effective in reducing the occurrence of similar incidents.