Policy

Respond to all incidents, accidents and emergencies involving clients by:

1. Assuring the safety of all persons involved;
2. Fully documenting and reporting the occurrence internally and externally to appropriate authorities;
3. Participating in resolving the problem and/or preventing future occurrences; and
4. Cooperating fully with authorized investigating agencies.

Risk Assessment

Most important in assuring client safety is Risk Assessment. While risks are identified in assessment documents like the Functional and Health and Wellness Assessments, onging risk assessment should take place each time you visit a client.

Each direct service Progress note prompts you to assess for the following risks:

• Suicidal ideation
• Threats of or behavior indicating potential self harm
• Threats of or behavior indicating potential harm to others
• Threats to safety in current relationships, social and interpersonal risk, or behavior that may prompt harm from others
• Disorientation, wandering
• Substance abuse presenting imminent risk of harm to self
• Self neglect in basic needs, medication, personal care, etc.
• Risky behavior or impulsivity that could result in injury or illness, or financial loss (e.g. gambling, sexual encounters)
• Vulnerability to financial exploitation
• Unmanaged health problems presenting imminent risk
• Imminent risk of incarceration
• Current, or imminent risk of, unmet basic needs (housing, clothing, food, safety, health care)
• Imminent risk of loss of job or basic financial supports
• For children: credible threats to run away
• Other

Take Action When Risks are Identified

When identifying any of the above or other risks, take action. This might include:

• For medical emergencies: Call 911, stay on the line until given permission to hang up and then call your supervisor for guidance
• For credible threats of harm harm or violence to others made by your client : Contact your supervisor about your Duty to Warn (Tarasoff Warning)
• For suspected or observed abuse or neglect: report abuse or neglect of children or vulnerable adults immediately using a Maltreatment Report and contact your supervisor for additional guidance on reporting. If harm is imminent or occuring, take action to prevent/stop it.
• Other: contact your supervisor for guidance.

Do not put yourself in harm's way with your intervention. If you are unable to intervene safely, or may be at risk of harm yourself, remove yourself from the situation and seek guidance.

Reportable Incidents General

Please note that the lists in this section describe incidents that you witness/that occur when you are with people. Read Reportable Incidents for Adults and Reportable Incidents for Children below for information about incidents to report when you are not with adults or children you serve but learn about them after-the-fact.

Accidents

Accidents that are reportable include accidents that occur when you are with the individuals you serve including the following:

• Any accident involving serious injury (defined below) to a client or the loss or destruction of property of a client.
• Any accident involving serious injury (defined below) to others or the loss or destruction of property of others by a client.
• Any accident that might have resulted in serious injury (defined below) to a client or significant property loss by a client, or property loss or injury to others by a person served.
• Any other accident that might have had any of the above consequeces, but in which the consequences were avoided.

Crimes

Any crimes or suspected crimes committed against a person or property of a person you serve.

Terroristic threats against a person or property of a person you serve, his or her residence or workplace.

Fires

Any fires or other events at the residence or workplace of a person you serve that require the relocation of services for more than 24 hours, or circumstances involving a law enforcement agency or fire department related to the health, safety, or supervision of that person.

Death

The death of a person you serve is reportable as an incident when it is a result of suicide, accidental, unexpected, or under suspicious circumstances. Seek guidance from your supervisor for reporting and follow-up.

Maltreatment

All reports of maltreatment of adults and children are considered incident reports, but the identity of the reporter shall be kept confidential. For more information see Accend Services Policy for Reporting Possible Maltreatment of Adults or Children.

Missing Persons

A missing person or unexpected and unexplained absence of a person from his or her residence or workplace. Considering that many of the people we serve are homeless or transient, simply losing touch with such a person is not an incident. Consider a missing person incident one where a person goes missing from a stable home or family under suspicious circumstances.

Other Unusual Occurrences

Unexplained missing money or property of a person served.

Involvement of a person served - and/or the staff member while with person - with law enforcement officials, such as arrests, detainment, questioning as a witness to a crime, interrogation, etc.

Suspicious events or behavior involving friends, neighbors, acquaintances, family members, staff members, other service providers, etc., of a person served, that, in the judgment of the staff member, cause concern and should be reported.

Any other unusual occurrence that causes concern, and in the judgment of the staff member, should be reported even if only as a matter of record.

Reportable Incidents For Adults

Behavior Causing or Credibly Threatening Serious Harm, or Property Damage

Reportable Behavioral Incidents include incidents that occur when you are with individuals you service or when you become aware of threats in dialog with them, including, but not necessarily limited to the following (with exceptions described below for children served in the EIDBI program):

• Serious harm or injury to self or others.
• Severe property damage.
• Credible threats by persons served of serious harm or injury to others or damage to his or her property.
• Behavior that might have caused serious harm or injury to self or others or serious property damage, but the harm was prevented.
• Credible threats of serious harm or injury by others against persons we serve.
• Other behavioral incidents that you might feel should be reported as a matter of record.

Illness

Any unexpected or sudden-onset illness requiring treatment, monitoring, observation by or consultation with a medical professional, whether or not the treatment was obtained, including, but not limited to:

• Persistent and uncontrolled high fever or chills;
• Persistent and uncontrolled vomiting or nausea;
• Excessive coughing or coughing with bloody discharge;
• Uncontrolled bleeding;
• Unexpected or unusual seizures or spasms;
• Bloody stool or urine;
• Repeated or continued loss of consciousness;
• Loss of feeling in extremities or other parts of the body;
• Unusual blurred vision, dizziness or loss of hearing;
• Unusually confused or garbled speech;
• Unresponsiveness or loss of consciousness for any period of time;
• Intense or persistent pain;
• Any other condition in which medical treatment might be sought by a reasonable person.

Specific Medical Conditions

Respond to each of the following as described and report as incidents:

High or Low Blood Sugar

If blood sugar is over 300, encourage the individual to follow the protocols in diabetes treatment plan and consult his or her doctor.

If blood sugar is below 70, treat with the 15-15 rule: 15 grams of carbohydrates and recheck in 15 minutes, repeat until above 70.

Check out this tip sheet on the warning signs of low blood sugar.

High Blood Pressure

If a person has a blood pressure reading of 180/120 or greater and is experiencing any other associated symptoms of target organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision, or difficulty speaking then this is a hypertensive emergency. Call 9-1-1.

Injury

Any serious injury to a person you serve, regardless of cause. A "serious injury" is defined a one requiring treatment, observation or monitoring by, or consultation with a medical professional (nurse or physician), including, but not limited to:

• Loss of consciousness for any period of time;
• Lacerations and abrasions requiring treatment in a clinic or hospital;
• Broken bones (fractures);
• Dislocations;
• Irreversible mobility or avulsion of teeth;
• Injures to the eyeball requiring treatment or affecting vision for an extended period;
• Any suspected internal injury or bleeding;
• Permanent disfigurement;
• Second or third degree burns;
• Second or third degree frostbite;
• Near drowning;
• Choking, or obstruction or stoppage of breathing requiring outside intervention;
• Ingestion of poisons or other toxic or foreign substances and objects that are harmful;
• Heat exhaustion or sun stroke;
• Any other injury considered serious by a physician or for which medical treatment or observation was sought.
• A pattern of repeated minor injuries such as significant bruises, cuts, scratches of unknown origin.

Reportable Incidents For Children

Injuries

Reportable injuries to children include the following. Exceptions may apply with permission from parents or guardians. These exceptions must be documented in the child's treatment plan.

• require medical treatment or first aid, or incidents where advice was sought as to whether or not to seek medical treatment, even if the advice was that medical treatment was unnecessary or delayed with instructions to monitor for additional signs and symptoms of more serious injury (no parent/guardian exceptions)
• cause bruising or injuries that might have caused bruising even if the bruise does not appear while the child is in our care that day/shift (parent/guardian exceptions allowed) )
• cause visible cuts, scrapes, or scratches with exceptions (parent/guardian exceptions allowed) )
• that are apparent and unexplained upon arrival of the child for services, or arrival of the provider at home or elsewhere to provide services (no parent/guardian exceptions) )

Exceptions may be made at the request of the parent/guardian for minor injuries or injuries to children who are accident-prone as defined by parent or guardian and where medical treatment or first aid for the injuries was not necessary. )

Health and Medical Incidents

Reportable health and medical incidents with children include the following:

• poisoning or suspected poisoning)
• taking medication that was not prescribed or over-the-counter medication not approved by parent or guardian, including suspected incidents)
• swallowing objects or suspicion of swallowed objects)
• unexpected seizures)
• any other health emergency that requires hospitalization or treatment by a medical professional)

Behavior

Reportable behavioral incidents include the following. It is important to remember that for children, certain aggressive behaviors may be expected and are the reason for treatment. Each child's plan will define reportable behavior.

• is unexpected or out of the ordinary for the particular child and is dangerous, aggressive, or harmful (or potentially so) to others)
• causes reportable injury to other children or staff, even if the behavior might be expected of the child)
• involves the use or threatened use, of lethal weapons, or threats of serious harm reportable under other statutes or codes)
• represents a potentially chargeable criminal act)
• is unexpected and of a sexual nature (including, but not limited to, touching the private parts of other children or staff, exposure, invasion of personal privacy), excluding behavior that is expected based upon evaluation and diagnosis, and has been identified as an emphasis of treatment, or unless the parent/guardian has requested that all of these incidents also be reported)

Exceptions are allowed for behavior that is potentially dangerous, aggressive, or harmful (or potentially so) to others and the behavior does not result in reportable harm to others, and is an emphasis of treatment.

Other Incidents

Other reportable incidents include the following:

• must be reported as maltreatment (use maltreatment report)
• results in contact with law enforcement or emergency services personnel (calling 911 regarding the incident)
• includes incidents/behaviors that parents or guardians have requested we report as an incident, whether or not the incident fits the above definitions
• results in early termination of services for the shift/day because of the risks it presents or other serious potential consequences

Use of Emergency Involuntary Holds or Restraints

The following lists when the use of any emergency restraints are allowed:

• To assure the safety of the person served or others
• Due to behavior that will (without intervention) cause serious injury,
• When staff members cannot remove themselves or others from harm's way

Report holds using the Involuntary Hold report form. An additional Incident Report is not necessary. Read this policy in the Positive Behavioral Redirection, De-Escalation and Intervention Guide. When an Involuntary Hold is used during an EIDBI session, flag the Progress Note with the add-on "Involuntary Hold Reported".

Procedures for Responding To Incidents

Direct Services Staff/Reporter

Take all possible and necessary steps to assure the immediate and long-term safety of the client to the best of your ability, as follows:

1. Call 911 in an emergency.
2. Report crimes against the client by calling 911.
3. For behavioral health crises, implement the client's behavioral health crisis plan, and help the client to contact crisis resources.
4. Contact non-emergency medical transportation if appropriate, or make other arrangements to transport the client to the hospital as needed.
5. Stay with the client until his or her safety can be reasonably assured.
6. Contact the on-call supervisor, as needed, for additional advice or counsel.

Program Manager

Upon receiving an Incident Report:

1. Assure the immediate and continuing safety of the individual to any extent possible;
2. Investigate the possible cause of the incident;
3. Interview/debrief staff and witnesses as needed to determine possible cause or contributing factors;
4. Identify and take actions to prevent future occurrences of the incident as possible;
5. Consult with:
• The team's nurse for medical incidents as needed
• The team's Clinical Lead (Supervisor) for clinical concerns
• The Program Director as needed, and for maltreatment or other legal questiions
6. Report as necessary and required to all necesary outside persons or agencies;
7. Document all investigative notes and actions and file with the original incident report.

Responding to Hospitalization

When our clients are hospitalized unexpectedly for serious conditions, we must immediately act to coordinate discharge planning. Many of the people we serve may have no other supports or resources for help. Many may experience implicit bias inherent in our health care systems because of the color of their skin, their socio-economic status, or their mental health conditions.

Case Managers and Behavioral Health Home staff, this is an expected part of the service. If other service providers become aware of a client hospitalization of this nature, they should immediately contact the Case Manager/Systems Navigator, who in turn should contact the hospital social worker to coordinate.

For ARMHS-only clients, discharge coordination can be done using the services ARMHS Transition to Community Living (if done face-to-face with the client present) or ARMHS Community Intervention TCL if done by phone or by contact with others (not the client). This service requires prior-authorization from some payers, but this authorization often cannot be obtained prior to the service. Request internal authorization for either of these services from your Program Manager before providing them.

For all other services to individuals without Case Management or Behavioral Health Home Services, contact your Program Manager for authorization and instructions for documenting your time.

Immediately Upon Hospitalization

Check the individual's Crisis Plan, or check with the individual if possible for:

• Supports in place for home maintenance and security.
• Care for pets.
• Finanical and bill payment supports
• Medical and other apppointments that may be scheduled during hospitalization or recuperation that may need rescheduling.
• Help needed contacting friends, family, other service providers and informal support networks.

Document the hospitalization (if admitted for even one night) as a temporary residence.

What Should Discharge Coordination Look Like?

Well before the discharge, connect with the hospital social worker or unit staff to:

• Learn of the possible discharge date and discharge criteria.
• Identify what care the individual may need post-discharge.
• Provide your contact information and ask to be contacted if the discharge occurs earlier than expected.

Additionally,

• Identify whether or not the individual has adequate, safe housing to go to upon discharge.
• Identify what other informal or formal supports the indivdual may need at home upon discharge and help facilitate these supports.
• If the individual has other in-home services (such as PCA or Home Health), coordinate with them on a post-discharge care and emergency plan. Do not assume that this provider will make these plans or is even aware of the hospitalizaion.
• Assure that the individual has adequate supplies of medications.
• Make a safety plan with the individual that includes safety checks as needed.
• Contact your team's supervising nurse to report your activities and seek additional guidance as needed.

Following the Hospitalization

Do the following:

• If there was no crisis plan in place create one now and update existing one based on the experience
• Did we/do we have the releases we needed or will need to, and if not, update them now.
• Document and report all actions in detail, including incident or sentinal event procedures in this chapter.
• Verify that the post-discharge safey plan is being implemented by all providers and informal support persons.

Procedures for Reporting Internally

Report all incidents internally prior to the end of the shift on which the incident occurs, as follows:

1. Contact your Program Manager to report the incident verbally;
2. Document the incident fully using an the Incident Report in Tabs^TM, or,
3. In the case of maltreatment, a Report of Possible Maltreatment form; and
4. Make reference to the Incident Report in client progress notes as applicable.
5. The Program Manager should notify the Program Director of all incident reports filed.

When documenting incidents involving other clients as witness to, or involved in the incident, do not use the names of other clients in the Incident Report record. File separate incident reports in those clients' records as needed.

Procedures for Reporting Externally and Cooperating With External Investigators

Once a staff person has reported an incident internally, the supervisor or director who receives the report will assure that the report is forwarded to the client's case manager and legal representative within 24 hours or within other deadlines defined by them in the client's service plan, and to other persons or agencies as identified in the client's plan. Additionally, Accend Services will report specific incidents externally as follows:

Crimes against a client: Report crimes against a client to law enforcement by calling (or helping the client call) 911, and report as maltreatment.

Maltreatment: Report possible maltreatment of adults to the CEP of the county where the client resides. Report maltreatment of children to the Initial Intervention Unit, Child Abuse Prevention, or other department of the county health and human services/social services agency or other law enforcement agency.

Serious Injuries and death of clients with mental illness or developmental disabilities: Report to the Ombudsman for Mental Health and Developmental Disabilities or using the forms found at that website.

Documentation, Record-Keeping and Cooperation with Investigators

Accend Services shall keep complete records of all incidents and investigation notes in each client's file and will make available to authorized investigating agencies all records associated with and/or related to the incident reported. Accend Services will cooperate fully in any investigation by making staff and witnesses available to authorized investigators for interviews and questions.

Procedures for Internal Investigation

Upon recieving a report of any incident, the Program Manager, Program Director, or another delegate shall fully investigate the report as follows:

1. The investigator shall interview all parties, including staff, clients and witnesses as necessary to obtain information about the cause of the incident, contributing factors, whether or not policies and procedures were followed;
2. Determine actions that need to be taken to correct or resolve problems;
3. Report as necessary to authorities, and respond to inquiries from investigating officials, media, etc.

Sentinel Events

Definition

A Sentinel Event is defined by The Joint Commission (TJC) as:

• any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, including suicide, not related to the natural course of the patient's illness, or events that may have resulted in harm but harm was prevented or avoided, including:
• an adverse event is a safety event that resulted in harm to an individual served.
• a no-harm event is a safety event that reaches the individual served but does not cause harm
• a close call is a safety event that did not reach the individual served
• a hazardous (or “unsafe”) condition(s) is a circumstance (other than an individual’s own disease, process, or condition) that increases the probability of an adverse event

Not being a facility, Accend has adapted this definition as best practice. We will respond to, investigate and report Sentinel Events described above when we learn of them when they occur with the people we serve, and when those events:

• occur on our premises;
• occur in other health care settings accessed by the people we serve;
• occur in the homes of persons we serve as a result of environmental or other conditions of which we were aware; or
• are the result of crimes committed against or by people we serve;
• and
• all suicides or attempted suicides;
• any maltreatment of a vulnerable adult or child perpetrated by a staff member of Accend Services, as determined to be maltreatment by our internal investigation, regardless of the determination by external investigators as to whether or not the incident constitutes maltreatment.

Investigation and Response

The Program Director or delegate will lead investigations of sentinel events. The investigation shall include:

• Interviews with all provider staff for the person served, witnesses and others.
• Root-cause and contributing factors analysis of the event, asking why the event occurred and exploring in depth the circumstances that led to it, to determine where improvements can be made.
• A determination if changes in any policies, procedures, staff training or other actions are necessary to prevent future occurences of this or similar events.
• A determination as to how and to whom the event must be reported externally.
• A report and recommendations, if any, to the Executive and Clinical Director.

The Program Director will keep a log of sentinal events and investigations.

Progress Notes for Incident Reporting and Debriefing

Document Incident Reporting activity, including maltreatment reporting (filing the report, debriefing, or consulting, etc.) as follows. Tag your supervisor, the Program Director, and others as needed by tapping the Click here to request that others read this note link in either type of note.

• If reported during/as a part of another service: use the Progress Note Add-On: Incident Report Filed.
• If done as a stand alone activity no additional documentation is necessary, unless:
• If documenting an incident report write-up takes more than 45 minutes, explain your gap time in your INOUT note for the shift
• If the time spent is debreifing on the incident report is with and administrative or clincal supervisor, document Being Supervised (Clinically or Administratively).

References

• > Mn Statute 245.91 -Definition of Serious Injury
• > The Joint Commission Sentinal Events Policy/Procedure

Feedback or Questions about this Chapter

This guide is a living document. We want to improve it with your help. Do you have questions? Found a typo? Find yourself wanting more information? Please send us your thoughts about anything in this chapter by tapping on the link below.

Updates to this Chapter

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Chapter re-titled to include Client Safety.

Risk Assessment section added.

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