Management of Incident Reporting, Investigation Process

1 11 2018 ARTHUR J. GALLAGHER & CO. | of Incident reporting , Investigation ProcessPresented By:Jane Feagin, Kerri Locker & Tammy Bowman2 2018 ARTHUR J. GALLAGHER & CO. | OBJECTIVES cont.: Be able to describe the Process for reporting and investigating an Incident Learn the Process to determine the root cause of and Incident . Understand the importance of trending and tracking incidents and how these steps can help reduce exposures Be able to describe how these techniques can be used as a proactive approach to reduce the risk for 2018 ARTHUR J. GALLAGHER & CO. | Management DEFINED:An ongoing Process of identifying,analyzing, controlling, financing andmanaging of risks for our residents,employees, visitors, community 2018 ARTHUR J. GALLAGHER & CO. | DEFINED: An unexpected, unintended event that may not be consistent with the routine operation of the facility or the routine care of a particular resident.

2 It may involve an injury or property 2018 ARTHUR J. GALLAGHER & CO. | Miss/Close Call Defined A near miss is an event that signals a system weakness that if not remedied could lead to significant consequences in the 2018 ARTHUR J. GALLAGHER & CO. | COMMON RISKS requiring Incident Investigation Accident or injury of known or unknown origin that was unusual or suspicious in nature such as extensive bruising, pain, or injury that is not consistent with actions necessary in providing day to day care to a resident or for which medical treatment was sought47 2018 ARTHUR J. GALLAGHER & CO. | COMMON RISKS requiring Incident Investigation A fracture or an injury resulting in medical attention. The onset of wandering behavior by any resident who is not fully cognitively intact Elopement by a 2018 ARTHUR J. GALLAGHER & CO. | COMMON RISKS requiring Incident InvestigationSuspected, alleged, or actual abuse of a resident or residents by staff, visitors, or other residents.

3 This includes all types of abuse including mental abuse, physical abuse, sexual abuse, and verbalabuse as defined in these 2018 ARTHUR J. GALLAGHER & CO. | COMMON RISKS requiring Incident Investigation Suspected, alleged, or actual neglect of a resident or residents Suspected, alleged, or actual exploitation of a resident or residents 10 2018 ARTHUR J. GALLAGHER & CO. | COMMON RISKS requiring Incident Investigation An unplanned occurrence that results in media attention. Intentional self-inflicted injury, suicide, or suicide attempt by a 2018 ARTHUR J. GALLAGHER & CO. | COMMON RISKS requiring Incident Investigation A medication error, overdose, or over sedation. Ingestion by a resident of a toxic substance that requires medical 2018 ARTHUR J. GALLAGHER & CO. | COMMON RISKS requiring Incident InvestigationAn outbreak (for purposes of these rules, anoutbreak is considered to be two or more affected people within 72 hours or less)of a contagious disease or condition including those listed in Appendix I to AlabamaAdministrative Code Sec.

4 (for example food-borne illness, scabies, influenza, or Staphylococcus aureus).713 2018 ARTHUR J. GALLAGHER & CO. | COMMON RISKS requiring Incident InvestigationA fire, earthquake, storm, other act of God,or other occurrence (for example, a natural gas leak or a bomb threat) that causes physical damage to the building inwhich the facility is located, or that results in the evacuation or partial evacuation of the 2018 ARTHUR J. GALLAGHER & CO. | COMMON RISKS requiring Incident InvestigationAny indication of malfunction of thesprinkler system, or fire alarm 2018 ARTHUR J. GALLAGHER & CO. | Your Employees Employees should know the facility policies on what is considered to be an accident or Incident and what event should generate the completion of an Incident report. Employees should be aware of the reporting requirements of accidents/incidents. Employees should be aware of the facility s commitment to providing a safe environment for residents, employees and visitors.

5 16 2018 ARTHUR J. GALLAGHER & CO. | REPORT DEFINED:anincident report is a Management tool forthe facility to record occurrences whichare not consistent with the routineoperation of the facility or routine careof a particular resident. It is used torecord facts of an occurrence with thepurpose of improving procedures to createa safer 2018 ARTHUR J. GALLAGHER & CO. | OF THE Incident REPORT Record facts about the Incident Notification to administration that an Incident has occurred Data for trending and tracking incidentsThe Incident report should be accurately completed with objective information 2018 ARTHUR J. GALLAGHER & CO. | 2018 ARTHUR J. GALLAGHER & CO. | MUST BE INVESTIGATED20 2018 ARTHUR J. GALLAGHER & CO. | Investigation PROCESSAn accident/ Incident Investigation Process is asystematic effort to determine whathappened, when it happened, how ithappened, where and why it happened, and towhom (Root Cause Analysis).

6 It shouldinclude what preventive measures should betaken to reduce and/or prevent a 2018 ARTHUR J. GALLAGHER & CO. | Investigation : (continued)The Investigation should include thedocumentation and preservation of informationcollected through the Investigation objective is to systematically identify ALLcontributing causes (root cause) of an Incident NOT TO FIND FAULT, but to understandWHY! The ultimate goal is to determine rootcause and to identify ways to reduce futurerecurrence of the 2018 ARTHUR J. GALLAGHER & CO. | Cause Analysis Has the Following Characteristics: Identify the event and investigate backwards; It repeatedly digs deeper by asking Why? until no additional logical answer can be identified; It is important to know the post-event actions but true cause may be determined by pre-event actions1223 2018 ARTHUR J. GALLAGHER & CO. | cause analysis can becompleted through the use of: Interviews Reviewing the medical record observing the resident or staff, reviewing training records, etc.

7 To determine ifpeople or processes caused the event24 2018 ARTHUR J. GALLAGHER & CO. | the EventThe first key step taken by a root causeanalysis team is to define the event! Describeas accurately as possible, what team might ask, What actuallyhappened? What created the red flag ? Examples: fall, skin breakdown, weight loss,missing articles, change in condition, 2018 ARTHUR J. GALLAGHER & CO. | Cause Analysis .. can be both reactive and proactive. Most frequently, the technique is used reactively -to probe the reason for problems that have already occurred. 26 2018 ARTHUR J. GALLAGHER & CO. | root cause analysis may be used proactively to even greater facility benefit to study processes in order to reduce the risk of future problems from ever 2018 ARTHUR J. GALLAGHER & CO. | (fall prevention) Speculate on risk factors of falls Actions based on conjecture Actions based on predictionsReactive (post falls action) Investigate current falls as they occur Collect factual evidence from the fall event Collate, aggregate and study the causes of fallsTwo Tiered ApproachExample28 2018 ARTHUR J.

8 GALLAGHER & CO. | Investigation Process :Try to determinethe root cause ofthe incident1529 2018 ARTHUR J. GALLAGHER & CO. | completing an Incident Investigation , it isimperative to cover every aspect of the injuredparty s actions at the time of the Incident . Thefour main sources of information are: People/employee actions Environment/physical conditions Work methods/policies Equipment30 2018 ARTHUR J. GALLAGHER & CO. | Actions Who was involved? Who could have been involved? Placement Training EnforcementConsider the resident sperspective not just theemployee1631 2018 ARTHUR J. GALLAGHER & CO. | ConditionsThe environment is kept free from accidenthazards: Chemicals safely stored Proper water temperature Routine check of rooms/bathrooms Handrails Corridors Electrical safety Lighting Instant housekeeping32 2018 ARTHUR J. GALLAGHER & CO. | Methods/Policies Current policies and procedures falls, elopements, behaviors, medication errors Training upon hire, annually, as needed Enforcement who, when, what Unusual circumstances during a fire drill, inclement weather, power outage, staffing issues1733 2018 ARTHUR J.

9 GALLAGHER & CO. | Design and arrangement Training employee and resident perspective Maintenance34 2018 ARTHUR J. GALLAGHER & CO. | Supervision Refers to an intervention and means of mitigating the risk of an accident Facilities are obligated and required to provide adequate supervision Adequate Supervision is defined by the type and frequency of supervision, based on the individual resident s assessed needs and identified hazards in the resident 2018 ARTHUR J. GALLAGHER & CO. | a timeline of events:A timeline is a graphicchronology of an timeline can assistthe Investigation processto see the developingstory and direct theinvestigation toward filling the gaps that arerevealed. 36 2018 ARTHUR J. GALLAGHER & CO. | of a the steps leading up to the the story of what track the steps in an a basis for creating a final a background for documenting the Investigation process1937 2018 ARTHUR J.

10 GALLAGHER & CO. | The Medical Record Appropriate assessment of the resident Appropriate care planning for the resident (Did the care plan address risk factors from the assessment?) Appropriate implementation and monitoring of the care plan was it revised if necessary? Review whether the resident was adequately supervised Review recent entries to determine if there were any changes and if care plan was being followed has there been a significant change in status38 2018 ARTHUR J. GALLAGHER & CO. | INCIDENTSNOTE: STAFF MUST HAVE A CLEARUNDERSTANDING OF WHEN TO NOTIFYMANAGEMENT AND/OR CORPORATE STAFFOF INCIDENTS2039 2018 ARTHUR J. GALLAGHER & CO. | OF SCENE Draw pictures of the scene Pictures may be taken If equipment is involved and if applicable, secure the equipment (box equipment and tape the box (date, time and initial tape) or place equipment in a secure location (chain of custody must be preserved) 40 2018 ARTHUR J.)