Survey of Assaultive Behavior In IMDs Performance Improvement Project

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1 Survey of Assaultive Behavior In IMDs Performance Improvement Project Instructions: Phone: Assaultive Behavior: Unwanted physical contact in an aggressive way, including hitting, kicking, punching, slapping, spitting, pushing and biting another person and/or throwing an object that makes contact with another person. High end assault: those resulting in injury with follow-up requiring nursing intervention, including services ranging from an ice pack to a neurological check to transport to the Emergency Room. Assault just prior to dschg (within 5 days)? No.of days admit to assault Severity of Assault Who was involved? Law enforcemt Notified? Action Taken Comment Consumer's SSN - Last Admission Assault Last Name First Name DOB 4 digits Axis I Diagnosis Axis II Diagnosis Axis III (write in) Date Date Badenov Boris 12/12/ Cocaine Intoxication 317 Mild Mental Retardation 1/1/29 9/16/21 No No apparent injury or unknown Resident to resident No Law enforcemt took to EPS Fatale Natasha 5/5/ Specific Phobia 31. Paranoid Personality Disorder 1/1/21 9/16/21 No Minor injury not requiring tx Resident to staff Yes Law enforcemt took to jail Bear Yogi Pyromania 31.2 Schizoid Personality Disorder 3/1/21 9/16/21 Yes 19 3 Minor injury requiring tx Resident to visitor No Staff took to EPS Flintstone Wilma 3.11 Conversion Disorder 5/1/21 9/16/21 Unknown Moderate w in-house tx Unknown AMR took to EPS Coyote Wylie 6/1/21 9/16/ Moderate w ER visit Remained at IMD, PD report taken VanPelt Lucy 7/1/21 9/16/ Major, serious or life threatening Remained at IMD, no PD report taken 8/1/21 9/16/ Death 9/1/21 9/17/21 7 1/31/211 C:\Temp\Temporary Internet Files\OLK5AE\Assaultive Behavior form xls

2 Survey of Assaultive Behavior In IMDs Performance Improvement Project Facility: Preparer: Phone: Instructions: See worksheet labeled "Instructions" Assaultive Behavior: Unwanted physical contact in an aggressive way, including hitting, kicking, punching, slapping, spitting, pushing and biting another person and/or throwing an object that makes contact with another person. NOTE: If resident is not a Santa Clara County client, see instructions Last Name First Name Consumer's DOB SSN - Last 4 digits Axis I Diagnosis Axis II Diagnosis Axis III (write in) no more than 5 Admission Date Assault Date Assault w/in 5 days of dschg? No.of days admit to assault Severity of Assault Who was involved? Law enforcemt Notified? Action Taken Comment 1/31/211 C:\Temp\Temporary Internet Files\OLK5AE\Assaultive Behavior form xls

3 Instructions: 1. Please complete the information on this form for each assault that meets the definition below. 2. Data should be collected for October 1 through December 31, 21. (a portion of October will be retroactive). 3. If using this as an electronic form, select items from the drop down menus in selected cells 4. If completing as a paper form, use the items from the worksheet labeled "answer selections" 5. If client is from outside Santa Clara County: Last name = your facility abbreviation, CWC, GLC, 7th Ave. First name = OOC plus client's initials, last name then first name example: client's name is Wilma Flintstone, first name column = OOC-FW 6. Axis III should contain up to 5 diagnoses that have the most impact on the resident's behavior. If the resident has more than 5 Axis III diagnoses, note this in the comments column and your observation on how it affects the resident's assaultive behavior 7. Comments: include relevant information such as -- issues regarding medication compliance medication reactions multiple Axis III that impact behavior, e.g. severe or chronic pain, terminal illness precipitating events, e.g. cutting in line, noisy or intrusive behavior, physical response to verbal assault specific event, e.g. upset by family visit, fear of leaving facility 8. Questions? or call Please data sheets one week after the end of each month Assaultive Behavior: Unwanted physical contact in an aggressive way, including hitting, kicking, punching, slapping, spitting, pushing and biting another personand/or throwing an object that makes contact with another person. A huge thank you for doing this!

4 DSM-IV-TR Classification, Diagnosis Axis I: 29. Dementia of the Alzheimer's Type, With Late Onset, Uncomplicated 29.1 Dementia Due to Creutzfeldt-Jakob Disease 29.1 Dementia Due to Pick's Disease 29.1 Dementia of the Alzheimer's Type, With Early Onset, Uncomplicated Dementia of the Alzheimer's Type, With Early Onset, With Delirium Dementia of the Alzheimer's Type, With Early Onset, With Delusions Dementia of the Alzheimer's Type, With Early Onset, With Depressed Mood 29.2 Dementia of the Alzheimer's Type, With Late Onset, With Delusions Dementia of the Alzheimer's Type, With Late Onset, With Depressed Mood 29.3 Dementia of the Alzheimer's Type, With Late Onset, With Delirium 29.4 Vascular Dementia, Uncomplicated Vascular Dementia, With Delirium Vascular Dementia, With Delusions Vascular Dementia, With Depressed Mood 291. Alcohol Intoxication Delirium 291. Alcohol Withdrawal Delirium Alcohol-Induced Persisting Amnestic Disorder Alcohol-Induced Persisting Dementia Alcohol-Induced Psychotic Disorder, With Hallucinations Alcohol-Induced Psychotic Disorder, With Delusions Alcohol Withdrawal Alcohol-Induced Anxiety Disorder Alcohol-Induced Mood Disorder Alcohol-Induced Sexual Dysfunction Alcohol-Induced Sleep Disorder Alcohol-Related Disorder NOS 292. Amphetamine Withdrawal 292. Cocaine Withdrawal 292. Nicotine Withdrawal 292. Opioid Withdrawal 292. Other (or Unknown) Substance Withdrawal 292. Sedative, Hypnotic, or Anxiolytic Withdrawal Amphetamine-Induced Psychotic Disorder, With Delusions Cannabis-Induced Psychotic Disorder, With Delusions Cocaine-Induced Psychotic Disorder, With Delusions Hallucinogen-Induced Psychotic Disorder, With Delusions Inhalant-Induced Psychotic Disorder, With Delusions Opioid-Induced Psychotic Disorder, With Delusions Other (or Unknown) Substance-Induced Psychotic Disorder, With Delusions Phencyclidine-Induced Psychotic Disorder, With Delusions Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder, With Delusions Amphetamine-Induced Psychotic Disorder, With Hallucinations Cannabis-Induced Psychotic Disorder, With Hallucinations Cocaine-Induced Psychotic Disorder, With Hallucinations Hallucinogen-Induced Psychotic Disorder, With Hallucinations Inhalant-Induced Psychotic Disorder, With Hallucinations Opioid-Induced Psychotic Disorder, With Hallucinations Other (or Unknown) Substance-Induced Psychotic Disorder, With Hallucinations Phencyclidine-Induced Psychotic Disorder, With Hallucinations

5 Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder, With Hallucinations Amphetamine Intoxication Delirium Cannabis Intoxication Delirium Cocaine Intoxication Delirium Hallucinogen Intoxication Delirium Inhalant Intoxication Delirium Opioid Intoxication Delirium Other (or Unknown) Substance-Induced Delirium Phencyclidine Intoxication Delirium Sedative, Hypnotic, or Anxiolytic Intoxication Delirium Sedative, Hypnotic, or Anxiolytic Withdrawal Delirium Inhalant-Induced Persisting Dementia Other (or Unknown) Substance-Induced Persisting Dementia Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Dementia Other (or Unknown) Substance-Induced Persisting Amnestic Disorder Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Amnestic Disorder Amphetamine-Induced Mood Disorder Cocaine-Induced Mood Disorder Hallucinogen-Induced Mood Disorder Inhalant-Induced Mood Disorder Opioid-Induced Mood Disorder Other (or Unknown) Substance-Induced Mood Disorder Phencyclidine-Induced Mood Disorder Sedative-, Hypnotic-, or Anxiolytic-Induced Mood Disorder Amphetamine Intoxication Amphetamine-Induced Anxiety Disorder Amphetamine-Induced Sexual Dysfunction Amphetamine-Induced Sleep Disorder Caffeine-Induced Anxiety Disorder Caffeine-Induced Sleep Disorder Cannabis Intoxication Cannabis-Induced Anxiety Disorder Cocaine Intoxication Cocaine-Induced Anxiety Disorder Cocaine-Induced Sleep Disorder Cocaine-Induced Sexual Dysfunction Hallucinogen Intoxication Hallucinogen Persisting Perception Disorder Hallucinogen-Induced Anxiety Disorder Inhalant Intoxication Inhalant-Induced Anxiety Disorder Opioid Intoxication Opioid-Induced Sexual Dysfunction Opioid-Induced Sleep Disorder Other (or Unknown) Substance Intoxication Other (or Unknown) Substance-Induced Anxiety Disorder Other (or Unknown) Substance-Induced Sexual Dysfunction Other (or Unknown) Substance-Induced Sleep Disorder Phencyclidine Intoxication Phencyclidine-Induced Anxiety Disorder Sedative, Hypnotic, or Anxiolytic Intoxication Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder

6 Sedative-, Hypnotic-, or Anxiolytic-Induced Sexual Dysfunction Sedative-, Hypnotic-, or Anxiolytic-Induced Sleep Disorder Amphetamine-Related Disorder NOS Caffeine-Related Disorder NOS Cannabis-Related Disorder NOS Cocaine-Related Disorder NOS Hallucinogen-Related Disorder NOS Inhalant-Related Disorder NOS Nicotine-Related Disorder NOS Opioid-Related Disorder NOS Other (or Unknown) Substance-Related Disorder NOS Phencyclidine-Related Disorder NOS Sedative-, Hypnotic-, or Anxiolytic-Related Disorder NOS 293. Delirium Due to...[indicate the General Medical Condition] Psychotic Disorder Due to...[indicate the General Medical Condition], With Delusions Psychotic Disorder Due to...[indicate the General Medical Condition], With Hallucinations Mood Disorder Due to...[indicate the General Medical Condition] Anxiety Disorder Due to...[indicate the General Medical Condition] Catatonic Disorder Due to...[indicate the General Medical Condition] Mental Disorder NOS Due to...[indicate the General Medical Condition] 294. Amnestic Disorder Due to...[indicate the General Medical Condition] Dementia Due to... [Indicate the General Medical Condition Without Behavioral Disturbance Dementia of the Alzheimer's Type, With Early Onset, Without Behavioral Disturbance Dementia of the Alzheimer's Type, With Late Onset, Without Behavioral Disturbance Dementia Due to... [Indicate the General Medical Condition], With Behavioral Disturbance Dementia of the Alzheimer's Type, With Early Onset, With Behavioral Disturbance Demential of the Alzheimer's Type, With Late Onset, With Behavioral Disturbance Amnestic Disorder NOS Dementia NOS Cognitive Disorder NOS Schizophrenia, Disorganized Type Schizophrenia, Catatonic Type Schizophrenia, Paranoid Type Schizophreniform Disorder Schizophrenia, Residual Type Schizoaffective Disorder Schizophrenia, Undifferentiated Type 296. Bipolar I Disorder, Single Manic Episode, Unspecified Bipolar I Disorder, Single Manic Episode, Mild Bipolar I Disorder, Single Manic Episode, Moderate Bipolar I Disorder, Single Manic Episode, Severe Without Psychotic Features Bipolar I Disorder, Single Manic Episode, Severe With Psychotic Features Bipolar I Disorder, Single Manic Episode, In Partial Remission Bipolar I Disorder, Single Manic Episode, In Full Remission Major Depressive Disorder, Single Episode, Unspecified Major Depressive Disorder, Single Episode, Mild Major Depressive Disorder, Single Episode, Moderate Major Depressive Disorder, Single Episode, Severe Without Psychotic Features Major Depressive Disorder, Single Episode, Severe With Psychotic Features

7 Major Depressive Disorder, Single Episode, In Partial Remission Major Depressive Disorder, Single Episode, In Full Remission Major Depressive Disorder, Recurrent, Unspecified Major Depressive Disorder, Recurrent, Mild Major Depressive Disorder, Recurrent, Moderate Major Depressive Disorder, Recurrent, Severe Without Psychotic Features Major Depressive Disorder, Recurrent, Severe With Psychotic Features Major Depressive Disorder, Recurrent, In Partial Remission Major Depressive Disorder, Recurrent, In Full Remission Bipolar I Disorder, Most Recent Episode Hypomanic Bipolar I Disorder, Most Recent Episode Manic, Unspecified Bipolar I Disorder, Most Recent Episode Manic, Mild Bipolar I Disorder, Most Recent Episode Manic, Moderate Bipolar I Disorder, Most Recent Episode Manic, Severe Without Psychotic Features Bipolar I Disorder, Most Recent Episode Manic, Severe With Psychotic Features Bipolar I Disorder, Most Recent Episode Manic, In Partial Remission Bipolar I Disorder, Most Recent Episode Manic, In Full Remission Bipolar I Disorder, Most Recent Episode Depressed, Unspecified Bipolar I Disorder, Most Recent Episode Depressed, Mild Bipolar I Disorder, Most Recent Episode Depressed, Moderate Bipolar I Disorder, Most Recent Episode Depressed, Severe Without Psychotic Features Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features Bipolar I Disorder, Most Recent Episode Depressed, In Partial Remission Bipolar I Disorder, Most Recent Episode Depressed, In Full Remission Bipolar I Disorder, Most Recent Episode Mixed, Unspecified Bipolar I Disorder, Most Recent Episode Mixed, Mild Bipolar I Disorder, Most Recent Episode Mixed, Moderate Bipolar I Disorder, Most Recent Episode Mixed, Severe Without Psychotic Features Bipolar I Disorder, Most Recent Episode Mixed, Severe With Psychotic Features Bipolar I Disorder, Most Recent Episode Mixed, In Partial Remission Bipolar I Disorder, Most Recent Episode Mixed, In Full Remission Bipolar I Disorder, Most Recent Episode Unspecified Bipolar Disorder NOS Bipolar II Disorder Mood Disorder NOS Delusional Disorder Shared Psychotic Disorder Brief Psychotic Disorder Psychotic Disorder NOS 299. Autistic Disorder Childhood Disintegrative Disorder Asperger's Disorder Pervasive Developmental Disorder NOS Rett's Disorder 3. Anxiety Disorder NOS 3.1 Panic Disorder Without Agoraphobia 3.2 Generalized Anxiety Disorder 3.11 Conversion Disorder 3.12 Dissociative Amnesia 3.13 Dissociative Fugue 3.14 Dissociative Identity Disorder 3.15 Dissociative Disorder NOS

8 3.16 Factitious Disorder With Predominantly Psychological Signs and Symptoms 3.19 Factitious Disorder NOS 3.19 Factitious Disorder With Combined Psychological and Physical Signs and Symptoms 3.19 Factitious Disorder With Predominantly Physical Signs and Symptoms 3.21 Panic Disorder With Agoraphobia 3.22 Agoraphobia Without History of Panic Disorder 3.23 Social Phobia 3.29 Specific Phobia 3.3 Obsessive-Compulsive Disorder 3.4 Dysthymic Disorder 3.6 Depersonalization Disorder 3.7 Body Dysmorphic Disorder 3.7 Hypochondriasis 3.81 Somatization Disorder 3.82 Somatoform Disorder NOS 3.82 Undifferentiated Somatoform Disorder 3.9 Unspecified Mental Disorder (nonpsychotic) Cyclothymic Disorder 32.2 Pedophilia 32.3 Transvestic Fetishism 32.4 Exhibitionism 32.6 Gender Identity Disorder in Children 32.6 Gender Identity Disorder NOS 32.7 Sexual Dysfunction NOS Hypoactive Sexual Desire Disorder Female Sexual Arousal Disorder Male Erectile Disorder Female Orgasmic Disorder Male Orgasmic Disorder Premature Ejaculation Dyspareunia (Not Due to a General Medical Condition) Sexual Aversion Disorder Fetishism Voyeurism Sexual Masochism Sexual Sadism Gender Identity Disorder in Adolescents or Adults Frotteurism 32.9 Paraphilia NOS 32.9 Sexual Disorder NOS 33. Alcohol Intoxication 33.9 Alcohol Dependence 34. Opioid Dependence 34.1 Sedative, Hypnotic, or Anxiolytic Dependence 34.2 Cocaine Dependence 34.3 Cannabis Dependence 34.4 Amphetamine Dependence 34.5 Hallucinogen Dependence 34.6 Inhalant Dependence 34.6 Phencyclidine Dependence 34.8 Polysubstance Dependence 34.9 Other (or Unknown) Substance Dependence

9 35. Alcohol Abuse 35.1 Nicotine Dependence 35.2 Cannabis Abuse 35.3 Hallucinogen Abuse 35.4 Sedative, Hypnotic, or Anxiolytic Abuse 35.5 Opioid Abuse 35.6 Cocaine Abuse 35.7 Amphetamine Abuse 35.9 Phencyclidine Abuse 35.9 Caffeine Intoxication 35.9 Inhalant Abuse 35.9 Other (or Unknown) Substance Abuse Vaginismus (Not Due to a General Medical Condition) 37. Stuttering 37.1 Anorexia Nervosa 37.2 Tic Disorder NOS Transient Tic Disorder Chronic Motor or Vocal Tic Disorder Tourette's Disorder 37.3 Stereotypic Movement Disorder Insomnia Related to... Indicate the Axis I or II Disorder it is related to Primary Insomnia Hypersomnia Related... Indicate the Axis I or II Disorder it is related to Primary Hypersomnia Circadian Rhythm Sleep Disorder Sleep Terror Disorder Sleepwalking Disorder Dyssomnia NOS Nightmare Disorder Parasomnia NOS 37.5 Eating Disorder NOS Bulimia Nervosa Pica Rumination Disorder Feeding Disorder of Infancy or Early Childhood 37.6 Enuresis (Not Due to a General Medical Condition) 37.7 Encopresis, Without Constipation and Overflow Incontinence 37.8 Pain Disorder Associated With Psychological Factors Pain Disorder Associated With Both Psychological Factors and a General Medical Condition 37.9 Communication Disorder NOS 38.3 Acute Stress Disorder 39. Adjustment Disorder With Depressed Mood Separation Anxiety Disorder Adjustment Disorder With Anxiety Adjustment Disorder With Mixed Anxiety and Depressed Mood 39.3 Adjustment Disorder With Disturbance of Conduct 39.4 Adjustment Disorder With Mixed Disturbance of Emotions and Conduct Posttraumatic Stress Disorder 39.9 Adjustment Disorder Unspecified 31.1 Personality Change Due to...[indicate the General Medical Condition] 311 Depressive Disorder NOS

10 312.3 Impulse-Control Disorder NOS Pathological Gambling Kleptomania Pyromania Intermittent Explosive Disorder Trichotillomania Conduct Disorder, Childhood Onset Type Conduct Disorder, Adolescent Onset Type Conduct Disorder, Unspecified Onset Disruptive Behavior Disorder NOS Selective Mutism Oppositional Defiant Disorder Identity Problem Reactive Attachment Disorder of Infancy or Early Childhood Disorder of Infancy, Childhood, or Adolescence NOS 314. Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type Attention-Deficit/Hyperactivity Disorder, Combined Type Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type Attention-Deficit/Hyperactivity Disorder NOS 315. Reading Disorder Mathematics Disorder Disorder of Written Expression Expressive Language Disorder Mixed Receptive-Expressive Language Disorder Phonological Disorder Developmental Coordination Disorder Learning Disorder NOS [Specified Psychological Factor] Affecting...[Indicate the General Medical Condition] Medication-Induced Postural Tremor Neuroleptic-Induced Acute Dystonia Neuroleptic-Induced Tardive Dyskinesia Medication-Induced Movement Disorder NOS Neuroleptic Malignant Syndrome Neuroleptic-Induced Acute Akathisia 347 Narcolepsy Male Erectile Disorder Due to...[indicate the General Medical Condition] Male Dyspareunia Due to...[indicate the General Medical Condition] Male Hypoactive Sexual Desire Disorder Due to...[indicate the Medical Condition] Other Male Sexual Dysfunction Due to...[indicate the General Medical Condition] 625. Female Dyspareunia Due to...[indicate the General Medical Condition] Female Hypoactive Sexual Desire Disorder Due to...[indicate the General Medical Condition] Other Female Sexual Dysfunction Due to...[indicate the General Medical Condition] 78.9 Delirium NOS Sleep Disorder Due to... Indicate the General Medical Condition, Insomnia Type Sleep Disorder Due to... Indicate the General Medical Condition, Hypersomnia Type Breathing-Related Sleep Disorder Sleep Disorder Due to... Indicate the General Medical Condition, Mixed Type Sleep Disorder Due to... [Indicate the General Medical Condition], Parasomnia Type 78.9 Age-Related Cognitive Decline Encopresis, With Constipation and Overflow Incontinence

11 799.9 Diagnosis Deferred on Axis II Diagnosis or Condition Deferred on Axis I Adverse Effects of Medication NOS Neglect of Child (if focus of attention is on victim) Sexual Abuse of Child (if focus of attention is on victim) Physical Abuse of Child (if focus of attention is on victim) Physical Abuse of Adult (if focus of attention is on victim) Sexual Abuse of Adult (if focus of attention is on victim) V15.81 Noncompliance With Treatment V61.1 Partner Relational Problem V61.12 Physical Abuse of Adult (if by partner) V61.12 Sexual Abuse of Adult (if by partner) V61.2 Parent-Child Relational Problem V61.21 Neglect of Child V61.21 Physical Abuse of Child V61.21 Sexual Abuse of Child V61.8 Sibling Relational Problem V61.9 Relational Problem Related to a Mental Disorder or General Medical Condition V62.2 Occupational Problem V62.3 Academic Problem V62.4 Acculturation Problem V62.81 Relational Problem NOS V62.82 Bereavement V62.83 Physical Abuse of Adult (if by person other than partner) V62.83 Sexual Abuse of Adult (if by person other than partner) V62.89 Phase of Life Problem V62.89 Religious or Spiritual Problem V65.2 Malingering V71.1 Adult Antisocial Behavior V71.2 Child or Adolescent Antisocial Behavior V71.9 No Diagnosis on Axis II V71.9 No Diagnosis or Condition on Axis I

12 DSM-IV-TR Classification, Diagnosis Axis II: 31. Paranoid Personality Disorder 31.2 Schizoid Personality Disorder Schizotypal Personality Disorder 31.4 Obsessive-Compulsive Personality Disorder 31.5 Histrionic Personality Disorder 31.6 Dependent Personality Disorder 31.7 Antisocial Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Borderline Personality Disorder 31.9 Personality Disorder NOS 317 Mild Mental Retardation 318. Moderate Mental Retardation Severe Mental Retardation Profound Mental Retardation 319 Mental Retardation, Severity Unspecified Neuroleptic-Induced Parkinsonism V62.89 Borderline Intellectual Functioning More --->

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20 Law enforcement notified? Yes No Unknown Severity of assault 1 No apparent injury or unknown 2 Minor injury not requiring tx 3 Minor injury requiring tx 4 Moderate w in-house tx 5 Moderate w ER visit 6 Major, serious or life threatening 7 Death Action Taken Law enforcemt took to EPS Law enforcemt took to jail Staff took to EPS AMR took to EPS Remained at IMD, PD report taken Remained at IMD, no PD report taken Who was involved Resident to resident Resident to staff Resident to visitor

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