TARRY HOUSE, INC.
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Subject: Incident
Reporting Procedure |
Procedure Number:
H.S. 13 |
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Site: Tarry
House and Tarry House Respite |
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Issued By: Executive
Director |
Effective: |
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Approved By: The
Board of Trustees |
Revised: |
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Reference Policy:
HS 01 |
Reviewed: |
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Standards Reference: |
CARF: 1. E. 10 ODMH: 5122-30-16 |
Approved: |
I.
Purpose
It
is the policy of Tarry House Inc. to insure prompt, accurate investigation and
reporting of incidents involving persons served, staff and visitors.
II.
Policy
All
staff is responsible for reporting incidents that occur at the Tarry House
Recovery Home, at Respite, or in the community. All staff will ensure that all
incident reports are complete and that the Program Manager or the Executive
Director is notified as quickly as safely possible.
III.
Procedure
A Minor Incident – is any occurrence, which is not consistent with the
routine care of the persons served. Incidents may involve persons served,
staff, visitors in Tarry House facilities, on grounds or in the community. A
Minor Incident Report shall be completed when a person is considered “Absent
without Notice” (AWON).
Major Incidents - According to the Ohio Department of Mental Health
(5122-30-03); “Major Unusual Incident” means an occurrence likely to cause
serious harm which is not consistent with the routine care of a person served
or routine operation of the facility.
Incidents may involve persons served, facility staff, or visitors. Major incidents shall include all deaths,
serious bodily injuries, alleged criminal acts, alleged abuse or neglect, any
adverse reaction of a person served to a life threatening degree due to an
administered drug, medication errors likely to result in serious consequences
to a person served, and any life threatening situation. Also, major unusual incidents include, but
are not limited to the following: alleged
assaults to an employee and/or other persons, alleged criminal act, property
damage of $300.00 or more, bomb threats, serious disruption of facility
essential services, utilities and safety systems, serious suicide attempts or serious
self abusive behavior, serious injury such as deep lacerations and fractures;
any fire that results in an injury and/or that a fire department responded to
and extinguished and/or that caused the evacuation of a building.
Suicide or Attempted Suicide – There is no more critical incident than when someone completes
or attempts a suicide. Staff members are
expected to utilize the knowledge and experience gained from their initial and
ongoing training in first aid, CPR, and crisis prevention and intervention. There is no perfect way to prevent suicidal
behavior, but staff members are encouraged to follow these guidelines when
dealing with a potential suicide or a suicide attempt:
A.
Remember that
what you think is a crisis and what another person thinks is a crisis may be
two different things.
B.
Remember that the
ability to manage psychosocial and financial stressors differs from person to
person, and most people with a psychiatric diagnosis have difficulty coping.
C.
Take all threats of
suicide seriously, especially if the person verbalizes a plan or a particularly
accessible and lethal method (e.g., jumping from a bridge) and seek help. Good communication with your co-workers,
supervisor and the individual’s treatment team may be the key to saving
someone’s life.
D.
Contact emergency
personal if you believe someone has an imminent plan to harm him- or herself. If possible, stay with the person until help
arrives.
E.
If the person has
harmed him- or herself, provide emergency first aid and contact emergency
medical personnel. Once the person is
being treated by emergency medical personnel, contact your supervisor to
communicate what has happened and receive instructions.
F.
Following a major
incident of this nature, staff and those served will receive counseling as
needed by the Executive and/or Clinical Director of Tarry House. In addition, the incident will be discussed
in a staff meeting, with emphasis placed on what (if anything) could be done
differently or better in the future.
The
Ohio Department of Mental Health’s (ODMH) Incident Report Form DMH-LIC-015 (revised
11/21/2003) must be completed for all major unusual incidents involving persons
served, employees, or visitors on Tarry House grounds, in the community and/or
incidents that occur during all Tarry House sponsored community activities.
1.
The employee’s
supervisor should be notified of all MUI’s immediately.
2.
The Incident
Report is to be made in original only, and
forwarded to employee’s immediate supervisor.
3.
The supervisor will
ensure that the Major Unusual Incident Report Form is completed fully and
accurately. The supervisor will make
certain the MUI is faxed to the Summit County Alcohol Drug Addiction and Mental
Health Services Board (ADM Board) , the affiliating agency providing services,
the person’s guardian/custodian if applicable and ODMH within 24 hours after
the incident occurs or is discovered. If the incident occurs on the weekend,
notification, via fax, must be made the next business day. The Executive Director should be informed of
all MUI’s the next business day, unless the supervisor deems it necessary that
the Executive Director be notified immediately.
4.
For MUI’s that occur
in the Tarry House Recovery Home, after the MUI is faxed, the supervisor is to
complete the Tarry House, Inc. Incident Report Follow-up Form (attached to this
policy). For the Tarry House Treatment
Home, the original MUI with the attached follow-up form will be forwarded to
the Recovery Specialist for review and sign off. The Recovery Specialist will forward to the
Clinical Director who will review sign off and forward to the Executive
Director who will review, sign off and make sure it is filed
appropriately.
5.
At the Respite
Home, the Program Manager (or designee) first makes certain the MUI is faxed to
the entities indicated above. He or she then completes the MUI follow-up form, photocopies
it and forwards the original MUI and the original follow-up form, to the
Executive Director via interoffice mail. The envelope should be sealed and
clearly marked “confidential.”
Procedures for Managing Minor Unusual Incidents
1.
All Minor Incident
Reports must be completed before the end of the shift the incident
occurred. This original report form is
to be forwarded to the employee’s immediate supervisor.
2.
After the Minor
Incident Report is reviewed by the Program Manager, the Program Manager is to
complete the Tarry House, Inc. Incident Report Follow-up Form (attached to this
policy). For the Tarry House Recovery
Home, the original Minor Incident Report with the attached follow-up form will
be forwarded to the Recovery Specialist for review and sign off. The Recovery Specialist will forward to the
Clinical Director who will review, sign off and forward to the Executive
Director who will review, sign off and make sure it is filed appropriately.
3.
At the Respite
Home, the Program Manager (or designee) ensures the Minor Incident Report is
completed fully and appropriately and then completes the follow-up form. Both
the Minor Incident Report and the follow-up form should be photocopied, and the
originals should be forwarded to the Executive Director via interoffice mail.
The envelope should be sealed and clearly marked “confidential.”
Tracking and Analysis of Incidents
After the Executive Director
reviews all MUI’s and Minor Incident Reports, the reports will be forwarded to
the agency secretary/receptionist who will enter the appropriate statistics
into a data collection spread sheet to assist in analysis. The secretary will maintain files for all
incidents, major and minor. Incidents
reports will be maintained in a secure area.
A thorough analysis of all
incidents will be performed at the monthly administrative staff meeting.
Potential causes and trends will be identified. Action plans will be developed to
address the identified causes and trends. Action plans will be evaluated on a
weekly basis to determine their effectiveness at reducing risks and changes
made where appropriate. Additional
action to be taken (if necessary), incident trending and recommendations will
be discussed.
Debriefings are held as
deemed appropriate by the Clinical Director or Executive Director following
each emergency to provide support to personnel and the persons served. If
necessary, Tarry House, Inc. may have a crisis response team of trained
clinicians respond to staff and client needs following an emergency situation.
All debriefings shall be documented and kept with administrative staff meeting
minutes.
________________________________________ _____________________
Executive Director Date
Tarry House, Inc.
Incident Report Follow-up Form
(Internal
QI Form, do not fax to ODMH)
Name of Resident involved:
__________________________________Resident # ________
Date of the Incident: _________________ Time of
the Incident: ________________
Site Supervisor/Program Manager follow-up Information: _______________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Site Supervisor/Program
Manager Signature: _____________________________________________________
Date:
________________________
Recovery Specialist’s Comments (as needed):
___________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Recovery Specialist’s
Signature: _______________________________________________________________
Date:
________________________
Clinical Director’s Comments (as needed):
_____________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Clinical Director’s
Signature: ________________________________________
Date:
________________________
Executive Director’s Comments (as needed):
____________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Executive Director’s
Signature: ________________________________________________________________
Date:
________________________