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Client Safety, Accidents, Incidents and Sentinel Events

Welcome

This section describes policies and procedures for responding to and reporting accidents, incidents and sentinel events involving persons served.

For staff accidents and incidents, see Staff Health and Safety in the Career Development guide.

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:

Take Action When Risks are Identified

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

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:

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.

Helping Clients Obtain Firearms

Clients may ask for help obtaining firearms, conceal and carry permits.

Explain that this is not something we do as a part of any service.
Instead, encourage them to obtain this help from weapons sellers.

Learning of the presence in a home of firearms or other deadly weapons - or knowledge that a client or family member intends to obtain a firearm - that may not be stored or handled in a safe manner

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):

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:

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:

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.

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:

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.

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:

Use of Emergency Involuntary Holds or Restraints

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

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:
  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:

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:

Additionally,

Following the Hospitalization

Do the following:

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 TabsTM, 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:

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:

Investigation and Response

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

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.

References

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.

Questions, Feedback & Suggestions

Updates to this Chapter



Chapter re-titled to include Client Safety.

Risk Assessment section added.



Language added to Risk Assessment and Other Unusual Occurrences for identifying and potential reporting the presence in a home or possession by a client of firearms or other deadly weapons that may be unsafely stored or handled.



October 18, 2024: Callout added prohibiting staff from helping clients obtain firearms.