Bureau of Developmental Disabilities Incident Reporting
Incident reporting is required for all reports of abuse, neglect or exploitation of a consumer, violation of consumer's rights, and other "events or occurrences characterized by risk or uncertainty, resulting in or having the potential to result in significant harm or injury to an individual or death of an individual". Incidents must be reported according to BDDS Incident Reporting requirements. Adult or Child Protective Services will be notified of incidents when appropriate.
Abuse is defined as any of the following:
· Intentional or willful infliction of physical injury
· Unnecessary physical or chemical restraints or isolation
· Punishment with resulting physical harm or pain
· Sexual molestation, rape, sexual misconduct, sexual coercion and sexual exploitation
· Verbal or demonstrative harm caused by oral or written language, or gestures with disparaging or derogatory implications.
· Psychological, mental or emotional harm caused by unreasonable confinement, intimidation, humiliation, harassment, threats of punishment, or deprivation.
Incident Reporting Guidelines
Peak Community Services' staff respect the rights of all consumers. Abuse or neglect is incompatible with agency core values and is prohibited. All staff are expected to interact with consumers in a positive manner.
Any alleged violation by Peak Community Services employees will be handled via procedures outlined in the agency’s "Abuse / Neglect / Exploitation / Mistreatment of an Individual / Violation of an Individual's Rights Investigation Procedure".
Incidents must also be reported according to BDDS Incident Reporting requirements.
Reportable Incidents
Policy & Guidelines (BQIS – November 2007)
Reportable incidents are any event or occurrence characterized by risk or uncertainty resulting in or having the potential to result in significant harm or injury to an individual or death of an individual. Incidents may include the following:
This is the over-riding guide for determining if an incident is reportable. If the incident does not fit into one of the categories below, but fits into the statement above, it is reportable.
Incidents of suspected abuse or neglect of an adult or child who is residing in a community residential setting. All incidents falling in this category must also be reported to Adult Protective Services or Child Protective Services.
Physical, sexual, verbal, or mental abuse
Physical – includes willful infliction of injury, unnecessary physical or chemical restraints or isolation, and punishment resulting in physical harm or pain.
Report on the aggressor when:
1. the act is both intentional and aggressive
2. the act involves enough force to cause (or potentially cause) injury or pain.
Report on the victim if there is any physical or emotional injury or pain, or the individual reports being assaulted or abused.
Report any occurrences of mechanical restraint including locking in a room, tying in a chair, etc
Report any occurrence of chemical restraint, other than as prescribed by MD and approved by Human Rights Committee…Report these if you feel situation is abusive.
Sexual -- includes all allegations of rape sexual misconduct, or sexual exploitation.
Report ALL allegations, suspicions, and reports of sexual misconduct or exploitation. Report upon knowledge of allegation – do not wait until investigated!!!
Report staff / caregiver / other – report even if consensual.
Report consumer to consumer sexual activity – report if there is any suspicion that one is taking advantage of/exploiting the other.
Verbal – includes oral, written, and/or gestured language that included disparaging and derogatory remarks to consumers
Report Consumer to consumer – if the recipient is emotionally harmed.
Report Staff / Caregiver / Other to recipient – all oral, written, or gestured disparaging or derogatory remarks are reportable.
Mental – includes unreasonable confinement or intimidation.
Report:
1. Any punishment or action intended to cause shame or embarrassment.
2. Any threat made by non-consumer to consumer.
Neglect – includes failure to provide appropriate care, food, medical care or supervision
Report any situation when basic needs are not being met.
Report any situations in which family/staff are not following doctors orders.
Needs vs. Plan of Care – Not all items listed in the Plan of Care and ISP are needs. Missing a community outing or CHPI sessions would generally not be considered neglect or be reportable, although these do need to be addressed by the IDT. Contact your BDDS Service Coordinator if Team is unable to address program quality issues
Exploitation – All incidents falling in this category must also be reported to Adult Protective Services or Child Protective Services.
Financial – any deliberate misplacement, exploitation, or wrongful temporary or permanent use of an individual’s belongings or money.
Report any financial transaction between a staff and a consumer: There should be no co-mingling of funds. Consumer funds need to be kept separate—in consumers own checkbook.
Report any financial transactions between a provider and a consumer except those specifically allowed under provider standards.
Report any financial transaction with anyone if it appears the consumer is being taken advantage of.
Any other type of exploitation, including but not limited to sexual exploitation.
Report any situations in which the consumer is used for financial gain, for labor, for humor (making fun of them) etc.
Death of an individual – All deaths must also be reported to Adult Protective Services or Child Protective Services.
Also contact BQIS at (317) 234-3667 and your local APS/CPS.
A residence that compromises the health and safety of an individual due to a significant interruption of a major utility, such as electricity, heat, water, air conditioning, plumbing, fire alarm, or sprinkler system.
Report any time re-location is necessary due to lack or malfunction of utilities or specialized equipment.
Report when elevator or lift system which provides for entrance or egress is out of order.
Report situations or events “…that compromise the health and safety…”
There are two components here, time and individual need, which must be considered and require your judgment. Not having electricity for one hour may not compromise the safety of one consumer but be life threatening for another.
Environmental/ structural problems associated with a habitable residence that compromise the health and safety of an individual, including inappropriate sanitation, serious lack of cleanliness, rodents, structural damage, or damage caused by flooding, tornadoes or other acts of nature.
(Includes environmental events such as chemical spills.)
When do these become reportable???
Infestations: We do not expect you to file an Incident Report if you see a mouse. Report when it potentially affects/compromises the health and safety of an individual.
Do not report a few shingles blown off the roof.
Do report if enough damage is done that it affects the immediate living conditions of the house…rain is coming in…glass broken out, etc.
Think about what would be significant for your loved one.
Residential fire resulting in relocation, personal injury, property loss or other issues.
Report any accidental or unexpected fire.
Need multiple reports if more than one resident is involved.
Missing persons
Report anytime a consumer is missing.
Report willful elopement if the person becomes missing.
If a consumer leaves, but staff is able to follow and the person is not in significant danger, a report is not required -- HOWEVER, this does need to be tracked internally for patterns and Behavior Support Plan development.
If the individual is in danger (i.e. wandering in traffic) this would be reportable as “…an event or occurrence characterized by risk or uncertainty resulting in or having the potential to result in significant harm…”
When filing for an elopement or missing person, answer as many of the following as you can.…
· If individual has not returned or been found, what has / is being done to locate the person.
· How long was the individual gone?
· How long was it before staff realized that the individual was gone?
· What is the staffing level for this individual - how many hours of supervision
· does this individual receive on a daily or weekly basis (i.e., 24-7, 2 hours per day, etc.)?
· How did the individual elope / become missing without someone noticing?
· Where was the individual found?
· Who found the individual?
· How was the individual found (what condition were they in)?
· Was the individual at risk to her/himself and/or to others?
· Is there a history of previous elopements / missing persons with this individual?
· What measures are in place to prevent this in the future?
· Is there a behavioral support plan in place to address elopement missing persons?
· Any suspected criminal activity by staff members or individuals, including but not limited to theft, illegal drug use, and arson.
· Does not have to be an on-the-job violation.
· If there is any indication of consumer involvement, APS or CPS must be notified.
Consumer to staff aggression is reportable under this category as an act of battery. BQIS allows some discretion in reporting consumer to staff aggression, but a report must be filed in instances of staff injury, when there is a potential legal or employment consequence for the individual, or in which there was apparent pre-meditation or use of a weapon.
Any medical or psychiatric treatments/services (including emergency room visits) that resulted from events that had a potential for causing significant harm or injury or that require medical follow-up.
Report any behavioral event that led to evaluation at psychiatric facility or ER.
Report any accident, injury, or illness which led to evaluation at ER.
Report any in-patient admission—regardless of cause or reason.
Report visits to Immediate Care Centers only if used in an emergency situation.
Report medical follow-up defined as some procedure needed, ie cast removed, stitches removed, bandage changed, x-rays taken. If only visual check, not considered follow-up.
Has the individual had recent similar events?
Tell us the finding or diagnosis and medical or behavioral follow-up needed.
If team or CM has developed plan of action, let us know what this is.
Admission to a nursing facility, including respite stays.
Report when, where, and why. Whose decision?
Report estimated length of stay if known.
Report plans at discharge if known.
Injuries of unknown origin.
Report same as injuries of known origin below, but tell us what you are doing to find out cause of injury.
· Who found injury and when.
· Type and extent of injury
· What medical intervention was needed or provided, if any.
· Was Consumer in services (as opposed to being with family or friends) prior to discovery of injury?
Significant injuries including but not limited to:
· Injuries incurred while individual was restrained
· Fractures
· Burns greater than first degree
· Choking
· Large areas of contusions (bruising) or lacerations
Report any injury requiring anything more than basic first aid.
Report any choking event in which the individual was unable to breathe or cough for any period of time.
Report any bruise larger than the size of a quarter.
Report any laceration requiring more than a standard band-aid, or puncture wound penetrating deeper than skin.
What We Want To See:
Tell us how injuries/events occurred, how and who treated. Is medical follow-up necessary?
If you don’t know how occurred, tell us what you are doing to find out.
Tell extent of injury – compound fracture? Stitches needed?
Was EMS called?
Estimate size of bruise/laceration.
For Choking:
· Was the choking related to dining, pica, oral hygiene?
· What did the individual choke on?
· What interventions were used to clear the airway?
· Does the individual have a history of choking? If so, when was the last episode?
· Does the individual use any adaptive equipment, special positioning, or have dietary modifications regarding choking / swallowing? If so, were these used / implemented?
· Did the individual require medical attention?
RECENT CHANGE to GUIDELINES: If injury is known (directly observed) to have come from self-injurious behavior, and there is a Behavior Support Plan addressing this behavior, it does not need to be reported. If injury becomes significant (requiring professional medical intervention) it will need to be reported.
Medication errors.
Note: Refusal to take medications does not constitute an error and does not require filing of an incident report but should be followed up by medical personnel and the interdisciplinary team to ensure that the health and safety of the individual is safeguarded. This information should also be documented in the individual’s record.
· Wrong medication given that places the individual’s health and safety in jeopardy as determined by the personal physician.
· Wrong dose given that places the individual’s health and safety in jeopardy as determined by the personal physician.
· Missed medication that places the individual’s health and safety in jeopardy as determined by the personal physician.
· Medication given outside the prescribed administrative window that jeopardizes an individual’s health and safety as determined by the personal physician.
Report:
· All incidents of wrong medication given…
· All incidents of wrong dose of medication given…
· All incidents of missed medications given…
· All medications given outside of the prescribed administrative window…
· Repeated refusals which are noted to be of impact to the individual’s health...
…..EXCEPT in situations where the individual’s personal physician has indicated that the error does not jeopardize health or safety AND THIS IS DOCUMENTED.
This can be obtained in advance, but must be specific to the individual.
Inadequate staff supports resulting or having the potential to result in significant harm or injury to an individual or death of an individual. This includes inadequate supervision by staff, even when staffing levels are appropriate.
Report:
Occurrences of inadequate or non-existent supervision “…resulting or having the potential to result in…” harm or injury to the individual. This will include staff leaving prior to replacement staff arriving unless ISP specifically allows this unsupervised time, and staff sleeping.
What are the individual’s needs? What does the ISP call for? If the ISP calls for 20 hours of supervision and the individual received 16 hours, this is most likely reportable. If the ISP calls for 6 hours of ADL training, and the individual received 3 hours, then it is probably not reportable…was the health or safety of the individual compromised?
If 24/7 staffing is called for in the ISP/POC/CCB, and this is not provided, it must be assumed that health and safety needs are not being met and this is reportable.
What We Want To See:
Whenever possible, document exact times and dates of inadequate supervision, and individual responsible for providing supervision during the lapse.
Include level of supervision indicated in ISP.
Be specific as to how health or safety is jeopardized.
Inadequate medical support, including but not limited to failure to obtain needed follow-up medical appointments, failure to obtain routine or special dental or physician appointments, or failure to obtain medication refills in a timely manner.
Report if ISP or program rules mandate routine or special medical/dental evaluations or treatment, or physician orders are not followed, it is to be reported.
Report regardless of funding for procedures.
Use of any PRN medication related to an individual’s behavior.
Report any use of PRN medications prescribed for behavioral purposes, including pre-medical procedure sedation. (Note: Recent policy changes prohibit use of PRN medication for sedation prior to medical/dental appointments, but if used, must be reported.)
Report If administered by the treating doctor or medical facility at the time of treatment, it does not need to be reported.
Report Dual use medications: Why is it prescribed? Is it prescribed “....related to…behavior?” If prescribed for medical condition (i.e. seizures or insomnia) not reportable.
BQIS INCIDENT REPORT TRAINING TIPS
For Initial Reports….
Use the correct/legal name and social security number. No nicknames.
Fill out the service type correctly. This is the primary funding source – not the activity or location the individual is participating in at the time. Please check only one.
Do not submit a report with a future date (i.e. Client is scheduled for surgery on 7/1/05). The report will be returned as it cannot be downloaded into the database, and something may happen that prevents the event from taking place.
Check to be sure you have the correct year on the date.
Minimize use of Pronouns. . It can be difficult to figure out who all the he’s, she’s and they’s pertain to.
Be sure you fax or e-mail the report to the Service Coordinator. Emailing to BDDS Incident Reports does not automatically send to the BDDS Service Coordinator. Each district office has its own fax number.
All abuse, neglect, exploitation incidents, except self-injurious behaviors, require faxing or e-mailing it to your local APS/CPS office. Even if you are not sure, give them the information. They will either file it, act on it, or pitch it, but you will have notified them. Also, per BDDS Standards, if abuse, neglect, or exploitation is alleged by staff, then you are required to suspend staff. Reviewers will contact you requesting that staff be suspended if you do not address this in the report.
Do not restate information that is contained on the first page of the report (age, address, who was supervising, etc.). Only include diagnosis of the individual if it pertains to the incident.
An Associated Person is another person involved in the incident, not a witness. “Associated Person” section will be removed with the next modification to the system.
It is the responsibility of BQIS and the Incident Report Reviewers to decide when an incident is closed. Stating “Case Closed” or “No Follow-up Required” does not close the case. On occasion, closed incidents will be re-opened if additional information is received in follow-ups or from other sources.
Death Incident Reports
Please state in the narrative that the individual has “passed away”, as just checking the Death or Person box does not assure that this person actually died. We need a statement that specifically identifies the fact that the individual died, as we cannot assume that the person died.
*Follow-up Reports…
Check to be sure you have the correct name, SS# and birth date of the consumer. Avoid using knick-names.
Check to be sure you use the correct Incident Date (not date submitted) and Incident Number. If you don’t have the incident number, call us.
Check the initial report to be sure you have addressed the issues that were reported in the initial. New issues require a new incident report.
Use pronouns sparingly to avoid confusion.
Check to be sure you have the correct consumer listed on the follow-up report.
Do not combine several follow-up reports into 1. Each incident report must have its own follow-up report. (We will usually make an exception for med error reports, but call first)
Try to be complete but concise in the narrative.
