Incident Reporting PDF

Incident Reporting Identifying Incidents 10 CCR 2505-10 8.7411 Types of incidents requiring reporting include the following: 1. Death of a person receiving services a. When an individual dies an incident, report needs to be written and reported to Critical Incidents. 2...

Incident Reporting Identifying Incidents 10 CCR 2505-10 8.7411 Types of incidents requiring reporting include the following: 1. Death of a person receiving services a. When an individual dies an incident, report needs to be written and reported to Critical Incidents. 2. Hospitalization of person receiving services a. An IR needs to be written for both planned and unplanned hospitalizations. b. If the hospitalization is due to an unplanned medical emergency, the incident report needs to be reported to Critical Incidents. 3. Medical Emergencies a. This includes anything that takes a person to the hospital, urgent care or ER and does not result in admission. b. This also includes involvement with paramedics, EMTs, or other emergency medical personnel. c. Please reference Reporting Requirements for Incidents to know when to report as a critical incident. 4. Allegations of MANE (Mistreatment/Abuse/Neglect/Exploitation) a. All incidents – alleged or observed – must be reported. An incident does not need to be substantiated to be reported. b. All incidents of alleged or observed MANE/Mistreatment must be documented as an incident report and routed within 24 hours. c. Staff/Provider must follow Mandatory Reporting Guidelines for notifying law enforcement and Adult Protective Services (APS). 5. Injury to individual or Illness of individual receiving services a. Accidents (if someone falls or staff notices bruises, cuts, scrapes, etc. write up an IR). b. Any unusual markings or what appears to be bothersome issues to the client. This could be something as a minor scrap, cut or bruise. c. Write an IR even if there is not an apparent injury right away. d. Significant or serious illness, especially if the individual needs to be seen or evaluated by a medical professional. 6. Damage or Theft of an individual’s personal property a. Stolen personal items, regardless of whether or not the item was returned/found. b. Intentionally diverted medications c. Damage to any property attributed to an individual’s intentional or unintentional actions.  7. Errors in medication administration a. This includes any medication charting or distribution error. b. Medication errors which result in serious adverse effects must be reported as Critical Incidents 8. Lost or missing person receiving services a. All incidents when the whereabouts of individual is unknown. b. A person is considered missing if their unsupervised time is exceeded. c. If the missing person is at risk to themselves or community or their safety or the safety of the community is at risk, and/or missing beyond their window of unsupervised time in the community, the incident report needs to be reported to Critical Incident. 9. Criminal Activity a. All incidents when an individual receiving services commits or is accused of committing a crime b. All incidents when an individual receiving services violates legal/court orders, including parole violation 10. Aggression towards others a. Includes any physical aggression by a person receiving services towards any other person. b. If another individual receiving services is involved, ensure a separate incident report is completed for that individual. Ensure confidentiality by not including other individuals’ first and last names. 11. Incidents or reports of actions by persons receiving services that are unusual and require review 12. Self-Injurious Behavior (SIB) a. Injury or potential injury to the individual due to physical abuse that is self-initiated and self-directed by the client. Examples: head banging, biting, pinching, or hitting oneself b. An IR is not written for all SIBs, only those of the serious nature, or if the client does not have SIB tracking. c. Anytime an individual who has known self-injurious behaviors, engages in escalated behaviors or new self-injurious behaviors 13. Seizure of Unusual Nature a. Use this category to report a seizure or seizure-like behavior that is not typical, ie. lasting longer than normal. b. If an individual sustains an injury or requires involvement from emergency medical personnel, then categorize the incident as the most severe outcome, ie. medical emergency or hospitalization. Critical Incident Reporting Staff/Providers MUST report all potential Critical Incidents by calling their Coordinator or On-Call Coordinator IMMEDIATELY. Providers will then complete the Incident Report ASAP, as all Critical Incidents MUST be routed to the individual’s Case Management Agency (CMA) within 24 hours, even on the weekend or a holiday, and even when the person is out-of-services or out-of-State. What Requires a Critical Incident Report CRITICAL INCIDENTS MUST BE REPORTED FOR THE FOLLOWING: 1) DEATH Reportable whenever an individual in our services passes away. The cause of death, the names of any individuals involved, location of death and law enforcement involvement (if applicable) should all be listed 2) MISTREATMENT Reportable any time the incident qualifies as Mistreatment per statute (C.R.S. 25.5-10-202). Adult protection services (APS) and law enforcement mandatory reporting must be followed Specify what follow-up actions will be taken to keep the person safe and to prevent recurrence. For peer-to-peer Mistreatment, Critical Incidents must be routed for BOTH the victim and perpetrator. 3) INJURY/ILLNESS/MEDICAL EMERGENCY Reportable when a person is taken to Urgent Care or the Emergency Room for an illness or injury that requires treatment beyond first aid (stiches, fractures, dislocations, loss of limb, serious burns, skin wounds, pneumonia, etc.). Trips to the emergency room that do not meeting the criteria for emergent level of service and are screened out by emergency room staff should not be reported as a critical incident. This does NOT require admission to the hospital in order to be reported. If a diagnosis was received, include that in the Incident Report. 4) HOSPITALIZATION Reportable when a person in services needs emergency hospitalization, or admission to a psych ward/psychiatric hospital. This would NOT include scheduled surgeries. If a diagnosis was received, include that in the Incident Report. 5) DAMAGE TO CONSUMER’S PROPERTY/THEFT Deliberate damage, destruction, theft or use of a client’s belongings or money Deliberate diversion of medications 6) MEDICATION MANAGEMENT ISSUES  Reportable if a person in services suffers an adverse effect, harm, or needs medical care due to issues with medication dosage, scheduling, timing, set-up, compliance, administration, or monitoring (e.g., seizure suffered after missing seizure med). Name of the medication must be listed in the critical incident report 7) MISSING PERSON Reportable when an individual is missing beyond their window of unsupervised time in the community, and either their safety is at serious risk or there is a risk to public safety. 8) CRIMINAL ACTIVITY Reportable when an individual commits a criminal offense and there is law enforcement involvement, including a violation of parole or probation that will potentially result in the revocation of parole/probation. Any criminal offence committed by an individual that results in immediate incarceration. 8) UNSAFE HOUSING/DISPLACEMENT Reportable when an individual is residing in an unsafe living condition due to a natural event (e.g., fire or flood), or environmental hazard (e.g., infestation), and is at risk of eviction or homelessness. 9) OTHER HIGH-RISK ISSUES Includes substance abuse, victim of crime, suicide ideation, self-injurious behaviors, critical service interruption, etc. Frequently Asked Questions Should a CIR be submitted when individuals exhibit behaviors that are typical for him/her (e.g. self-injurious behaviors)? An important component of determining if an incident meets the definition of a critical incident is if the event creates immediate risk and/or serious harm to the health and welfare of the member receiving waiver services. If you are unsure if an incident meets reporting criteria, submit a CIR and the CMA will determine if it should not be classified as a CIR. Should a CIR be made every time an individual goes to the emergency department or hospital? No, scheduled medical procedures/surgeries should not be reported as a critical incident. Trips to the emergency room that do not meeting the criteria for emergent level of service and are screened out by emergency room staff should also not be reported as a critical incident. If you are unsure if an incident meets reporting criteria, submit a CIR and the CMA will determine if it should not be classified as a CIR. Should an urgent care visit be reported as a critical incident? Some, but not all, urgent care visits may be considered critical incidents. If the urgent care visit is used for emergency medical treatment or serious medical condition (e.g., stroke, broken bone, lacerations that require stitches, heart attack, etc.), this would be considered a critical incident and should be reported as such. If the urgent care visit is used in lieu of a primary care visit (e.g., cold, strep-throat, bronchitis, etc.), this would not be considered as critical, and a critical incident report should not be made. If you are unsure if an incident meets reporting criteria, submit a CIR and the CMA will determine if it should not be classified as a CIR. Are sexually transmitted diseases (STDs) considered a critical incident that requires a CIR? No, having an STD on its own is not a critical incident. However, if abuse is suspected as the reason for contracting an STD then a CIR should be submitted for the suspected abuse. Are peer-peer incidents considered critical incidents? Yes, if a peer-to-peer incident results in a serious risk to the health and safety of a member and meets CIR criteria, the incident must be reported as a critical incident. Peer-to-Peer incidents may also meet mandatory reporting requirements and staff/providers must follow the mandatory reporting process. If an individual has a fall that does not result in an injury, should this be reported as a critical incident? No, only falls that seriously impact the health and welfare of the individual should be reported as a critical incident. If you are unsure if an incident meets reporting criteria, submit a CIR and the CMA will determine if it should not be classified as a CIR. Documentation and Timely Reporting 1. All incidents will be documented by staff/provider with an incident report within twenty-four (24) hours. Staff/provider should use the incident report form in Evolv, Netsuite, or Setworks, which contains all elements required HCPF rule (10 CCR 2505-10 sections 8.7411 B and 8.7201.L.5). a. Staff/Providers who need assistance completing an incident report should contact their Supervisor/Coordinator or on-call Supervisor/Coordinator 2. Coordinator/Supervisor will review, initiate follow-up and route all non-critical incident reports to all authorized parties (guardian/authorized representative, Case Manager) within 48 hours of the incident 3. Critical Incidents, including allegations of Mistreatment, should be reported immediately and an incident report written as soon as possible. a. Staff/providers must notify their supervisor/coordinator or on-call supervisor/coordinator of potential critical incidents by phone immediately. b. Critical incidents must be routed to the individual’s CMA (case management agency) within 24 hours, even on the weekend or a holiday, and even when the individual is out-of-services or out-of-state c. Critical Incidents should be routed to the Imagine! Critical Incidents Team 4. Coordinator/ Supervisor or appropriate on-call Coordinator/Supervisor will route critical incident-reports within twenty-four (24) hours of the incident. 5. Any allegations of Mistreatment must be treated as a critical incident, reported immediately, and the incident report routed within twenty-four (24) hours  6. Incidents Reports shall include, but not be limited to: a. Name of the person reporting; b. Name of the Individual who was involved in the Incident; i. If more than one individual is involved, write a separate incident report for each person c. Name of persons involved or witnessing the Incident; d. Type of Incident; e. Description of the Incident; i. Descriptions should be detailed and objective. Incidents should provide a clear snapshot of the incident as it occurred, including details of what was happening in the individuals day prior to and during the incident, as well as how it was discovered f. Date and place of occurrence; g. Duration of the Incident; h. Description of the action taken in response to the incident; i. Provide detailed description of actions taken in response to the incident. Include what actions were taken to keep the individual safe i. Whether the Incident was observed directly or reported to the person writing the incident report; j. Names of persons notified; k. (Supervisor) Follow-up action taken or where to find documentation of further follow-up; and, l. (Supervisor) Name of the person responsible for follow-up. Reviewing and Routing Incident Reports Incident Reports will be reviewed by a variety of individuals both within the department and outside of the department. Each department determines who will review reports internally. The Executive Director or his/her designee will review the report and determine what next steps occur. Reports written by a day program are to be copied to the individual's residential program; incidents occurring in the residence are to be copied to the individual's day program. All Incident Reports will be sent to Case Management. Reports will be reviewed by the individual's Case Manager and the Case Management Director. They are then filed in the master record. Follow-Up to Incident Reports All incident reports require follow-up. A supervisor, coordinator, manager, nurse, or other designated person may add follow-up to the incident report, but staff and/or providers are responsible for writing detailed incident reports and providing additional information when requested. Follow up should include, who is responsible for the follow-up, what actions were taken to protect the health, safety and welfare of the individual(s); what actions will be taken to prevent a reoccurrence of the incident, and documentation that the incident was reviewed. The incident report should include the resolution of the incident, if there was one. The location of the documentation for the follow-up must be listed. Incident reports for alleged or witnessed Mistreatment (Mistreatment, Abuse, Neglect, Exploitation) must also include documentation relating to Mandatory Reporting. For example, when APS and Law Enforcement were notified, as well as APS and Law Enforcement case numbers and contacts. Mistreatment incident reports must also include any corrective action taken, e.g. the alleged perpetrator was removed from the home and put on suspension, or the individual was placed in emergency respite. Critical Incidents require additional follow-up, including but not limited to: a) Description of the incident, b) Immediate action taken to protect the health, welfare, and safety of the individual, c) Additional reporting (CDHS, CDPHE, Law Enforcement, Guardian), d) victims assistance referrals, e) Root cause analysis of incident-including whether the incident could have been prevented, f) Corrective action relevant to the incident. Writing an Incident Report How to Report an Incident Follow the documentation and timely reporting guidelines you received from your supervisor or coordinator. A written Critical Incident Report is required within 24 hours of the discovery of the actual or alleged incident. All other incidents must be written and routed within two business days. How to Write an Incident Report 1. Stop to think about what happened before beginning to write so that you are prepared to give factual, unbiased information. 2. Use the Incident Report form in Therap 3. Fill in the affected individuals full name, the date the incident occurred or the date you learned of the incident, and check the box indicating the type of incident. 4. DO NOT LEAVE ANY AREAS BLANK. Use N/A when the question or section is not relevant to the current incident. 5. Write your full name and date that you are writing the report. 6. Some people like to skip down to the description of the incident, then write the response section afterwards. 7. Put in all important details but avoid a long narrative. 8. Do not state opinions. 9. Was a Safety Control or Emergency Control procedure used? Fill in the requested information. 10. Sign and Date. 11. Submit to the Executive Director. or his/her designee within 24 hours! Commented [JG1]: This should probably be Therap specific, so I don’t want to mess with this too much right now Incident Report Scenario The following is a possible scenario for which an incident report would be required: Staff was at the library with Benny Bond on Tuesday, April 2, 2007. Benny threw a book which injured a child sitting nearby. Staff prepares an incident report. To report the incident: Write the agency name at the top. Enter the full date and time. Remember to use N/A when the question does not apply to this incident. Next, indicate the type of incident, witnesses (or yourself, if you the witness) and the Persons Notified section (nurse or others). Be brief and accurate. Remember that this is a permanent record. Do NOT use the full name/s of other consumers involved in the incident, for privacy reasons. A separate report must be written for the consumer who was injured (Eva, in this instance). Use descriptions that are accurate and polite. Do NOT use slang or derogatory comments. Commented [JG2]: Same with this, I think it should be Therap specific AND probably be about timely reporting, objectivity, or Critical Incidents