What, When and How to report& What happens after?
Risk Mitigation &Special Incident Reports
The North Bay Regional Center (NBRC) Risk Management and Mitigation Plan seeks to assure that all people served are safe and well through the review of Special Incident Reports, Mortality Reviews, Staff Training, the use of Risk Assessment Tools, and the development of strategies for qualityimprovementGoals: PreventionCommunicationCollaboration
NBRC’s Risk Management and Mitigation Plan is designed to conform with the specifications of Title 17 California Code of Regulations (54327.2) by addressing:The process used to report Special Incidents by NBRC staff, vendors and long-term health care facilities;NBRC’s obligation to train Service Coordinators and provide technical assistance to vendors;The evaluation of trends;andThe identification of effective systemic and programmatic interventions that will improve the health and safety of people receiving services
Closethe Loop on SIRPreventionAnticipate problems before they happenPerpetuate a self correcting system
What is a Special Incident?
Generally speaking, a special incident is something that has caused harm or has the potential to cause harmto a person receiving services.Special incident reports are used by direct care staff to communicate details of specific events in a consumer’s life.In addition, SIRs are used internally at NBRC to indicate trends and patterns, which helps to identify individual service needs as well as training topics for staff and care providers.
Who needs to report?
Title 17 mandates specific special incident types be reported to NBRC when they occur during the time the client was receiving services and supports from any vendor or LTC facility. These are referred to as “Reportable” incidents because they are required by DDS (Department of Developmental Services).Licensed care homesandsupported living agenciesare responsible for 24 hour care unless otherwise specified in the consumer’sIPP.Independent living services agencies and day programs are only responsible to report most incidents that occur during scheduled hours, which may vary depending on individual service needs.Regionalcenters will report all special incidents that they believe to have occurred under vendor care, regardless of the identity of the vendor – i.e. even if the vendor reporting to the regional center is not the vendor under whose care the incident occurred.Some incident types are not “Reportable” by Title 17/DDS standards, however NBRC requires them to assure quality of service and communication.
The following incident types (Victim of Crime,Suspected Abuse & Death) need to be reported immediately,regardlessof when or where they occur:
VICTIM OF CRIME
Crimes include:RobberyAssault with the intention of taking another’s property.BurglaryIllegally entering a building with the intent to take another’s property.LarcenyTheft of propertyAggravated AssaultRapeIncluding attempted rape
Include in your report:Date, time and placePerpetrator (if known)Specific description of incident including medical care received, property taken, etc.Law enforcement contacted?Follow up or preventative plans for the future.Outside agencies involved?APS, CPS, Police
Physical abusePhysical/chemical restraintEmotional abuseFinancial abuseSexual abuse
Include in your report:Date and time (approx ok)Perpetrator (if known)How abuse was discoveredMedical care receivedPlans to protect from future abuseOutside agencies involved?APS, CPS, Police
Failure to provide food/shelter/clothingFailure to provide medical careFailure to care for hygiene needsFailure to protect from health/safety hazardsFailure to provide care in generalIncluding self-neglect
Include in your report:Date and time, or length of time it has been suspected to be occurring.Suspected perpetrator (if known)Medical care receivedPreventative plansOutside agencies involved?APS, CPS, Police
Include in your report:Date and time of deathPlace of deathMedical care or treatment receivedincluding emergency care/911 if applicableSuspected cause of deathWas it expected? Predictable? Unexpected?Persons present at time of deathWho was notified?Name of funeral home being used (if known)If a death certificate is available, please include a copy with your report.
As a MANDATED REPORTER, it is your legal duty to report reasonably suspected abuse or neglect to the proper authorities!
Per T17 regulations, the following incident types must be reported when they occur while under vendored care:Report by phone, fax, or email not more than 24 hours after learning of the occurrence to NBRC;Written SIR due within 48 hours
HOSPITALIZATION OR SERIOUS INJURY
Hospital admissionRespiratoryCardiacDiabetesSeizureWound CareInternal infectionPsychiatricSerious injuryrequiring more than first aidLacerations requiring sutures (including stitches, staples and glue)BurnsFracturesDislocationsPuncture woundsBites (human or animal)
Include in your report:DateandtimeERvisitlonger 24hoursPertinent events leading up to injury or illnessName of hospital (for admissions specifically)Type of care receivedDischarge plansPreventative plans for the future.
MEDICATION ERRORS OR REACTIONS
Include in your report:Type of medication, including dosage and typical method of dispensing.For errors, what exactly happened, who was responsible, how was it discovered.For reactions, describe how the reaction was discovered (behavior, physical signs, etc.)Plans to correct and prevent errors in the future.Medical care (or advice) sought/received.
If a consumer has left home/program and has been gone for more than 3 hours, police must be notified (unless otherwise specified in the IPP).
Include in your report:Date and time consumer was last seen.Events leading up to AWOL.Attempts to find the person.When were police contacted.Was the person found? Where? When? By whom? Condition?Plans to prevent future AWOL
Emergency Room visitsDrug/alcoholabuseDisease outbreakLice, pink eye, other contagiousillnessLawenforcement involvement
ArrestsSuicidethreats orattemptsInjuryFrom seizureFrom behavior episodeFrom another consumerFalls (regardless of injury or non-injury)
“OTHER” INCIDENT TYPES
THINGS TO REMEMBER:
Always remember to include the following in your reports:Detailed description of incidentMedical treatment receivedEvents leading up to incident, if pertinentWho was involvedDischarge information (for ER/hospital visits)Plans to prevent future incidentsAlso note:If the incident involved more than one consumer, a separate SIR is needed for each person.If in doubt please report anyway.If an incident occurred and involved more than one vendor (e.g. day program and care home) reports are required from both vendors.
Agencies must report toNBRC SIR Coordinatorno more than 24 hours after learning of the incident.SIR Coordinator: 256-1259.A Special Incident Report must be submitted to NBRC SIR Coordinator within 48 hours.By email: SIR@nbrc.netBy fax: 707-256-1270
Licensed facilities must notify Community Care Licensing within 48 hoursIn cases of abuse or neglect, Adult Protective Services, Child Protective Services or Ombudsman must be notified as soon as possible to help investigate the allegations.Law enforcement must be notified in cases of victim of crime
Who Does What?
SIRCoordinator- receives and enters the SIR report into Sandis and transmits to DDS; notifies theSCSC- reviews the SIR to determine appropriate follow up within 90 days
QA staff - reviews Reportable SIRs for compliance and training needsQA nurse- reviews Reportable SIRs that involve medical issues
Once NBRC receives the initial report (verbal, by email, or by fax) the SC will begin their followup; to be completed within 90 daysNBRCstaff will review the SIR to ensure the safety of the individual(s) receiving services has been addressed by the reporting agency and, to assure all needed notifications have been made in accordance with the NBRCpolicy
NBRC staff may take no action if it appears the incident requires no further follow up and the agency responded appropriately to the incident; orNBRCstaff may contact the provider to obtain more information by speaking to staff, consumers, and/or complainants. In addition, copies of additional written documents may be requested.NBRC staff may conduct an on-site investigation independently, or in conjunction with other investigative entities
Title 17-http://www.dds.ca.gov/title17/T17SectionView.cfm?Section=56027.htmNBRC Service Provider webpage-http://nbrc.net/service-providers/special-incident-reports/DDS Safety Net-http://www.ddssafety.net//NBRC phone numbers:Napa 707-256-1100Santa Rosa: 707-569-2000After Hours: 800-884-3268 (evenings, weekends, holidays)