Policy/Procedure: Incident Management A 41 QUALITY LIFE CONCEPTS APPROVED BY: Board of Directors, 8/15/11 Original Date: FY06 REVIEW DATE: 5/11 Revision Date: 5/20/11 Version: Two Incident Management Scope: This procedure applies to all staff and affiliates of Quality Life Concepts (QLC). POLICY: The purpose of this policy is to establish the protocols and procedures for Incident Management for DD Services provided by QLC. This policy provides structure and develops a consistent system for the identification, documentation, and reporting of critical and reportable incidents. This policy is developed in accordance with the guidelines addressed within the Department of Public Health and Human Services, Developmental Disabilities Program (DPHHS/DDP), and other guiding entities. QLC s policy provides structure and develops a consistent system of incident reporting, trend analysis reporting, and critical incident investigations. Further, this policy provides an outline for the procedure of reporting incidents that bring harm, or have potential to bring harm, to clients served by staff who are providing supports or services to clients. Incidents that involve clients will be immediately and routinely identified by the Critical Incident Coordinator, reported, and reviewed as a part of QLC s internal quality management system. This policy defines the categories of incidents that involve clients as Reportable Incidents, Critical Incidents and incidents requiring reporting under the Montana Elder and Persons with Developmental Disabilities Abuse Prevention Act. Additionally, Critical Incidents, as identified by this policy, require reporting to designated authorities external to QLC, including, but not limited to family/guardians, DPHHS/DDP, Adult Protective Services (APS), Child Protective Services (CPS), Long Term Care Ombudsman, Certification Bureau or Licensing Bureau within required timeframes. The policy also aims to ensure the implementation of corrective action measures that will prevent the recurrence of similar incidents, along with other activities that will allow staff to be proactive in their responsibilities to reduce the risk of harm to clients. Information gathered from incident reporting and trend analysis will be utilized to assist in the development of Individualized Plans and training for staff. The Incident Management System, for the purpose of this policy, means the process of identifying incidents, classifying incidents, reporting incidents, conducting trend analysis reviews of incidents and reporting on those trends. The term also includes a process of conducting or assigning internal Critical Incident Investigations by the Critical Incident Coordinator. QLC will provide written notification to the required agencies, as indicated, using the approved incident management guidelines provided by DPHHS. Incidents are defined as events which happen on QLC premises, or during the provision of services that have or could have significant consequences to the health, safety, and welfare of program Page 1 of 7
participants and/or staff. Incidents are divided into two categories reportable and critical, dependent upon severity as defined in Appendix A of the Montana DDP Incident Management System Policy. QLC also requires the reporting of internal incidents, not necessarily required by State Policy. See Related Document #1. The following categories are mandated to be reported as outlined in Appendix A: 1. Aspiration/choking 2. Death 3. Discovery of contraband 4. Hospitalization 5. Medication error 6. Missing person 7. Injury to the client 8. Property damage 9. Mechanical restraint 10. Physical or manual restraint 11. Use of PRN medication for behavior 12. Use of exclusionary time out 13. Use of seclusion time out 14. Rights violation 15. Seizure 16. Self-injurious behaviors 17. Suicide threats or attempts 18. Ingestion of a harmful substance 19. Law Enforcement involvement 20. Abuse allegation involving physical injury to the client 21. Abuse allegation involving mental injury to the client 22. Abuse allegation involving exploitation of the client 23. Allegation of neglect of the client 24. Allegation of sexual abuse of the client 25. Allegation of mistreatment of the client 26. Allegation of physical abuse by the client 27. Allegation of mental abuse by the client 28. Allegation of exploitation by the client 29. Allegation of neglect by the client 30. Allegation of sexual abuse by the client QLC recognizes there are incidents that need to be reported in order to facilitate client health, safety and trends observations. As such, these incidents would fall within the reportable and internal level of incidents and mandates that the following incidents be reported: 1. Vehicular accidents while being transported in QLC vehicles or while participating in a QLC sponsored activity. 2. Communicable disease and infection control. 3. Acts of violence or aggression towards other clients, QLC staff or property, or citizens in the community. 4. Unusual or extraordinary behaviors that are out of the ordinary for a client. 5. Unusual or extraordinary marks, bruises, or injuries to the client. 6. Unusual conditions that may be or may become harmful or hazardous to the clients health and well being living condition of residence, self neglect, etc. 7. Bio-hazardous accidents to include accidents with chemicals used in day to day work assignments, blood borne pathogen exposures, etc. Page 2 of 7
8. Theft any evidence or suspicion of theft or mismanagement of monies or personal belongings - theft of client, QLC, and staff property or belongings. 9. Reporting incidents as identified by the PSP/IFSP team, QLC staff, or guardians specific to a client to assist in future planning. 10. Use of a PRN narcotic medication. 11. Inappropriate sexual actions. Responsibilities: A core value of this incident management policy is to encourage all staff to focus on proactive and preventative incident management to reduce the risk of harm to the client, to other clients served and to those providing services. This policy and procedure guideline should provide a framework that supports the development of effective corrective action(s) and/or intervention(s) that achieve the highest standards of quality services and supports for clients. By taking a proactive approach to incident reporting and conducting trend analysis, we will continue to provide accurate information to other care providers and provide more up to date information for individualized planning. QLC s staff members who provide support or services to clients are required to follow the Incident Management Policy and Procedure. Failure to follow the policy could lead to disciplinary action up to and including dismissal. Other Responsibilities: Retaliatory action is prohibited against the reporting personnel and those participating in the investigative process, by the service provider, an employee, and/or other person affiliated with the organization; Disciplinary actions will be taken against any person who is found guilty of retaliation against the reporter; Employees must report accurate information and participate in the incident management process as required. Disciplinary actions will be taken against an employee if he/she refuses; Any person who is found to have committed abuse, neglect, mistreatment, and/or exploitation, as defined by this policy, will be removed immediately from contact with clients and, as determined appropriate by QLC management, be subject to corrective action, discipline and/or termination in accordance with pertinent policies. Disciplinary actions will be taken against any employee who directs an employee not to report incidents. Staff are to take immediate action to intervene when they have knowledge of harm or the potential for harm to a client. If physical or psychological injury to the client is suspected, prompt medical assessment and/or treatment or contact with necessary community support personnel (i.e. counselor, social worker, etc), will be obtained as required. Any injury(s) suspected to be caused by abuse, neglect, or mistreatment be immediately examined by a medical professional and classified as an allegation of abuse, neglect, or mistreatment. Reports of incidents and required documentation are allowed to be received from any individual having knowledge of Reportable and Critical Incidents. Summary of incident report information, trend data, and results of investigations are maintained in the client s, and as appropriate in the employee's records and submitted to the QIS. (See Related Document #3.) Annually, employees of the provider or the family, responsible for direct care services receive in-service training required by DPHHS/DDP. (See Related Document #4.) Page 3 of 7
PROCEDURES: QLC staff will utilize MTDDP Incident Report Form, most current revision as detailed below: Instructions for completing the Incident Report Form: 1. The observer of the incident (or staff person involved) completes the Incident Report Form (IR) for any situation that meets the definition for a Reportable or Critical Incident (as specified in Appendix A of the DDP Incident Management Policy see Related Document #1) or for other incidents that QLC requires to record and track. 2. SECTION 1- DESCRIPTION OF THE INCIDENT: Section 1 will be completed by the observer or the staff person involved immediately or no later than end of shift when the incident has been identified or occurred. Fill in the last name of the client, first name of the client, date of the incident, time of the incident, and check a.m. or p.m. If the incident is discovered, and you don t know the time it happened, put in the time it was discovered. a. Circle the number for the region of the origin of the incident (Region 2), enter the name of the provider organization for whom the reporting staff works (QLC). b. The observer or staff person involved fills out the Description of Incident section: i. Under Describe What Happened, the incident is described in narrative fashion. The writer will: 1. Describe who was involved and other witnesses. Were other clients involved in the incident? If applicable, then use their initials. If so, the writer will need to fill out a separate incident form for the other client(s) involved. Identify all staff involved by name; 2. Describe what happened before the incident: including, a. environmental conditions, b. any cues given, c. any other salient environmental conditions: for example, a fire drill was in progress; 3. Describe the incident in observable and measurable terms; 4. Describe what occurred after the incident (with the individual within the environment); 5. Describe how long the incident lasted; and 6. Specify where the incident occurred. ii. Under Actions Taken, the writer will describe all actions taken to respond to or remediate the incident. The writer will: 1. Describe any actions to immediately protect from harm; 2. Describe any immediate actions to make the environment safe; 3. Describe any actions to provide first aid or seek emergency medical assistance; and 4. Identify supervisors and/or other persons notified of the incident. iii. Staff person will check the box indicating whether the incident was: 1. witnessed, where the writer was present or involved in the incident; or Page 4 of 7
2. discovered, where the writer identifies an incident but was not present, was not involved, or where the incident is suspected. iv. The writer will print their name and title under name/title of reporter. v. The writer will sign their name under signature of reporter. vi. The writer will enter the date the report was signed. vii. viii. ix. The writer will enter the time the report was signed. The writer will circle the number that best describes the reporter code. If the reporter is a staff person, circle 1. If the reporter is a client, 2. If the reporter is a family member, 3. If the reporter is a Targeted Case Manager (either contracted or DDP), 4. If the reporter is a staff member of DDP (but not a Case Manager), 5. If the reporter is any other person, 6 and describe the person on the line provided. Enter the names of people who witnessed the incident. If clients witnessed the incident, enter their initials. Staff will fill out sections 1, 4 (if injury occurred), and 5, notification (as appropriate) and routing information on the front of the form. Appropriate supervisors will sign in/fill out section 2, 3, 5, 6, & 7. 3. SECTION 2 SUPERVISOR REVIEW: QLC no longer requires supervisors to review IR s, however, on those occasions that supervisors see an IR, they will: Section 2 will be filled out by the reporting staff person and then the supervisor of the section/program of the agency where the affected client lives/works will sign in the appropriate area. When a supervisor reviews an IR, they are responsible to ensure it is filled out completely/correctly and that notifications have been made. Supervisors should not add to or correct Sections 1 or 4. If there are corrections, comments or additions to be made, you can write them in the Actions Taken part of Section 2 Supervisor Review. a. After reviewing the incident description, the supervisor enters the code for the cause of the incident. The codes for Client Action refer to the client that the IR is being written about. If an employee was directly involved in the incident, responsible for, or is suspected to be involved, then the employee is identified by name and the code number is entered. If another client is directly involved then the client s initials are entered and the appropriate code number is entered. If another person is directly involved, then that person is entered and the appropriate number entered. If the cause of the incident is suspected or observed to be the result of hazardous conditions of agency property (either equipment or the environment), or an unknown hazard, then the appropriate number is entered by the supervisor. b. The supervisor fills in the actual location and city of the incident s occurrence as the Primary Location. If the incident took place somewhere other than the group home, the address needs to be written in this area. c. The supervisor enters the appropriate number for the secondary location. d. Under Actions Taken the supervisor leaves the boxes blank that are either marked internal, reportable, or critical according to the definition of the type of incident (these will be marked by the Critical Incident Coordinator). The supervisor briefly describes action taken to manage the incident, signs the form, and enters the date and time of signature. NOTE: Page 5 of 7
Some providers wish to use the Incident Report Form to track other events not defined by the policy as either reportable or critical, for example, clientto-client aggression where there is no apparent injury as a result. For that reason the form is marked internal for the tracking of those other events. Otherwise, the box is checked based on the initial report of the incident. A box checked critical is not a determination of the outcome of the investigation, but rather is meant to flag the need for an investigation from the agency and/or the outside agency. See attached examples, including Med Error and Seizure Examples. 4. SECTION 4 MEDICAL/INJURY ASSESSMENT/TREATMENT a. If no treatment was given, put N/A, sign and date. b. If medical treatment was given either first aid or professional treatment, write in the type of treatment given, any medication, or follow-up prescribed. c. In the Injury Severity Section: i. Circle No Apparent Injury if there is no injury ii. If there is an injury, complete ALL four areas in this section 5. SECTION 5 NOTIFICATIONS 1. a. For all incidents fill out notification Section 5 as needed (i.e. on-call, case managers, QIS, QLC staff, family/guardian, APS/CPS if appropriate, etc.). See Appendix A for more clarification. Refer to the front of the log book in residential areas. When leaving messages, give your name, what location you are at, client(s) name, and what happened. i. Put the first and last name of the person(s) you called. ii. For on-call, write in the name of that person. iii. Date section: this is the date you made the notification. iv. Time: this is the time you made the notification, making sure to mark a.m. or p.m. v. Contacted by: this is the name of the person who made the contact (full name, not initials or just the first name of the person). vi. N. code: this is the notification code, the method used to contact the person, you will find the code across the top of the notification section. If two people are writing an IR about the same incident, only one set of notifications needs to be made, just put the same information on each IR. 2. OTHER INFORMATION a. Be sure that the document is free of attitudes and opinions. An opinion would be Kathy seemed sick today. The facts to be written would include Kathy did not eat dinner tonight and complained of a headache. Her fever was 99.8 at 5:55pm. She was given a Tylenol PRN at 6:00pm. She was resting in her room at 6:30pm and was sleeping at 7:00pm. I monitored her every half-hour until the AN staff arrived and reported her symptoms to him verbally with a request that he monitor her every halfhour or so. b. Medication errors the IR must include: i. Name of the medication ii. Dosage iii. Administration time Page 6 of 7
iv. If the nature of the error requires a call to the pharmacy, write down the name of the person you talked to and what they said. c. Timelines i. IR s should be written and notifications made before the end of the shift to ensure timely reporting ii. All IR s are to be turned into CIC no later than 10am the day after the incident. iii. Incidents are no longer routed to supervisors to allow for quick review for content and accuracy. Enforcement Failure by agency personnel to follow this procedure may result in disciplinary action, up to and including termination of employment. RELATED DOCUMENTS 1. Montana DDP Incident Management Policy http://www.dphhs.mt.gov/dsd/ddp/incidentmanagmentpolicy012210.pdf 2. Policy A 44 Investigations 3. Policy A 45 Reporting Timelines 4. Policy P 40 Employee Requirements Page 7 of 7