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POLICY AND PROCEDURE ON RESPONDING TO AND

REPORTING INCIDENTS

 

I.                    PURPOSE

The purpose of this policy is to provide instructions to staff for responding to and reporting incidents.

 

II.                 POLICY

The DAC will respond to incidents as defined in MN Statutes, section 245D.02, subdivision 11, that occur while providing services to protect the health and safety of and minimize risk of harm to the person(s) served. Staff will address all incidents according to the specific procedure outlined in this policy and act immediately to ensure the safety of persons served. After the situation has been resolved and/or the person(s) involved are no longer in immediate danger, staff will complete the necessary documentation in order to comply with licensing requirements on reporting and to assist in developing preventative measures. For emergency response procedures, staff will refer to the Policy and Procedure on Emergencies.

 

All staff will be trained on this policy and the safe and appropriate response and reporting of incidents. In addition, program sites will have contact information of a source of emergency medical care and transportation readily accessible. In addition, a list of emergency phone numbers will be posted in a prominent location and emergency contact information for persons served at the facility including each person’s representative, physician, and dentist is readily available.

 

III.               PROCEDURE

Defining incidents

A.     An incident is defined as an occurrence which involves a person and requires the program to make a response that is not a part of the program’s ordinary provision of services to that person, and includes:

1.      Serious injury of a person as determined by MN Statutes, section 245.91, subdivision 6:

a.       Fractures

b.      Dislocations

c.       Evidence of internal injuries

d.      Head injuries with loss of consciousness

e.       Lacerations involving injuries to tendons or organs and those for which complications are present

f.       Extensive second degree or third degree burns and other burns for which complications are present

g.       Extensive second degree or third degree frostbite and others for which complications are present

h.      Irreversible mobility or avulsion of teeth

i.        Injuries to the eyeball

j.        Ingestion of foreign substances and objects that are harmful

k.      Near drowning

l.        Heat exhaustion or sunstroke

m.    All other injuries considered serious by a physician involving complications of a previous injury or medical treatment

2.      Death of a person served.

3.      Any medical emergency, unexpected serious illness, or significant unexpected changes in an illness or medical condition of a person that requires the program to call “911,” physician treatment, or hospitalization.

4.      Any mental health crisis that requires the program to call “911,” a mental health crisis intervention team, or a similar mental health response team or service when available and appropriate.

5.      An act or situation involving a person that requires the program to call “911,” law enforcement, or the fire department.

6.      A person’s unauthorized or unexplained absence from a program.

7.      Conduct by a person served against another person served that:

a.       Is so severe, pervasive, or objectively offensive that it substantially interferes with a person’s opportunities to participate in or receive service or support

b.      Places the person in actual and reasonable fear of harm

c.       Places the person in actual and reasonable fear of damage to property of the person

d.      Substantially disrupts the orderly operation of the program

8.      Any sexual activity between persons served involving force or coercion as defined under MN Statutes, section 609.341, subdivisions 3 and 14.

9.      Any emergency use of manual restraint as identified in MN Statutes, section 245D.061.

10.  A report of alleged or suspected maltreatment of a minor or vulnerable adult under MN Statutes, sections 626.556 or 626.557.

 

 

Responding to incidents

A.     Staff will respond to incidents according to the following plans. For incidents including death of a person served, maltreatment, and emergency use of manual restraints, staff will follow the applicable policy and procedure:

1.      Death of a person served: Policy and Procedure on the Death of a Person Served

2.      Maltreatment: Policy and Procedure on Reporting and Review of Maltreatment of Vulnerable Adults or Policy and Procedure on Reporting and Review of Maltreatment of Minors

3.      Emergency use of manual restraint: Policy and Procedure on Emergency Use of Manual Restraint

 

B.     Any medical emergency (including serious injury), unexpected serious illness, or significant unexpected changes in an illness or medical condition of a person that requires the program to call “911,” physician treatment, or hospitalization

1.      Staff will first call “911” if they believe that a person is experiencing a medical emergency (including serious injury), unexpected serious illness, or significant unexpected change in illness or medical condition that may be life threatening and provide any relevant facts and medical history.

2.      Staff will give first aid and/or CPR to the extent they are qualified, when it is indicated by their best judgment or the “911” operator, unless the person served has an advanced directive. Staff will refer to the Policy and Procedure on the Death of a Person Served for more information.

3.      Staff will notify the Designated Coordinator and/or Designated Manager or designee who will assist in securing any staffing coverage that is necessary.

4.      If the person is transported to a hospital, staff will either accompany the person or go to the hospital as soon as possible. Staff will not leave other persons served alone or unattended.

5.      Staff will ensure that a completed Medical Referral form and all insurance information including current medical insurance card(s) accompany the person.

6.      Staff will remain at the hospital and coordinate an admission to the hospital. If the person served is not to be admitted to the hospital, staff will arrange for transportation home.

7.      Upon discharge from the hospital or emergency room, staff transporting to the program site will coordinate with the assigned nurse or nurse consultant, Designated Coordinator and/or Designated Manager or designee and ensure that:

a.       All new medications/treatments and cares have been documented on the Medical Referral form

b.      All medications or supplies have been obtained from the pharmacy

c.       All new orders have been recorded on the monthly medication sheet

d.      All steps and findings are documented in the program and health documentation, as applicable

8.      If the person’s condition does not require a call to “911,” but prompt medical attention is necessary, staff will consider the situation as health threatening and will call the person’s physician, licensed health care professional, or urgent care to obtain treatment.

9.      Staff will contact the assigned nurse or nurse consultant or Designated Coordinator and/or Designated Manager or designee and will follow any instructions provided including obtaining necessary staffing coverage.

10.  Staff will transport the person to the medical clinic or urgent care and will remain with the person. A Medical Referral form will be completed at the time of the visit.

11.  Upon return from the medical clinic or urgent care, staff will coordinate with the assigned nurse or nurse consultant, Designated Coordinator and/or Designated Manager or designee and ensure that:

a.       All new medications/treatments and cares have been documented on the Medical Referral form

b.      All medications or supplies have been obtained from the pharmacy

c.       All new orders have been recorded on the monthly medication sheet

d.      All steps and findings are documented in the program and health documentation, as applicable

 

C.     Any mental health crisis that requires the program to call “911,” a mental health crisis intervention team, or a similar mental health response team or service when available and appropriate.

1.      Staff will implement any crisis prevention plans specific to the person served as a means to de-escalate, minimize, or prevent a crisis from occurring.

2.      If a mental health crisis were to occur, staff will ensure the person’s safety, and will not leave the person alone if possible.

3.      Staff will contact “911,” a mental health crisis intervention team, or a similar mental health response team or service when available and appropriate, and explain the situation and that the person is having a mental health crisis.

4.      Staff will follow any instructions provided by the “911” operator or the mental health crisis intervention team contact person.

5.      Staff will notify the Designated Coordinator and/or Designated Manager or designee who will assist in securing any staffing coverage that is necessary.

6.      If the person is transported to a hospital, staff will either accompany the person or go to the hospital as soon as possible. Staff will not leave other persons served alone or unattended.

7.      Staff will ensure that a completed Medical Referral form and all current insurance information including current medical insurance card(s) accompany the person.

8.      Staff will remain at the hospital and coordinate an admission to the hospital. If the person served is not to be admitted to the hospital, staff will arrange for transportation home.

9.      Upon discharge from the hospital or emergency room, staff transporting to the program site will coordinate with the assigned nurse or nurse consultant, Designated Coordinator and/or Designated Manager or designee and ensure that:

a.       All new medications/treatments have been documented on the Medical Referral form

b.      All medications or supplies have been obtained from the pharmacy

c.       All new orders have been recorded on the monthly medication sheet

d.      All steps and findings are documented in the program and health documentation, as applicable

 

D.     An act or situation involving a person that requires the program to call “911,” law enforcement, or the fire department

1.      Staff will contact “911” immediately if there is a situation or act that puts the person at imminent risk of harm.

2.      Staff will immediately notify the Designated Coordinator and/or Designated Manager or designee of any “911,” law enforcement, or fire department involvement or intervention.

3.      If a person served has been the victim of a crime, staff will follow applicable policies and procedures for reporting and reviewing maltreatment of vulnerable adults or minors.

4.      If a person has been sexually assaulted, staff will discourage the person from bathing, washing, or changing clothing. Staff will leave the area where the assault took place untouched, if it is under the DAC’s control.

5.      If a person served is suspected of committing a crime or participating in unlawful activities, staff will follow the person’s Coordinated Service and Support Plan Addendum when possible criminal behavior has been addressed by the support team.

6.      If a person served is suspected of committing a crime and the possibility has not been addressed by the support team, the Designated Coordinator and/or Designated Manager will determine immediate actions and contact support team members to arrange a planning meeting.

7.      If a person served is incarcerated, the Designated Coordinator and/or Designated Manager or designee will provide the police with information regarding vulnerability, challenging behaviors, and medical needs.

E.      Unauthorized or unexplained absence of a person served from a program

1.      Based on the person’s supervision level, staff will determine when the person is missing from the program site or from supervision in the community.

2.      Staff will immediately call “911” if the person is determined to be missing. Staff will provide the police with information about the person’s appearance, last known location, disabilities, and other information as requested.

3.      Staff will immediately notify the Designated Coordinator and/or Designated Manager or designee. Together a more extensive search will be organized, if feasible, by checking locations where the person may have gone.

4.      The Designated Coordinator and/or Designated Manager or designee will continue to monitor the situation until the individual is located.

5.      If there is reasonable suspicion that abuse and/or neglect led to or resulted from the unauthorized or unexplained absence, staff will report immediately in accordance with applicable policies and procedures for reporting and reviewing maltreatment of vulnerable adults or minors.

 

F.      Conduct by a person served against another person served

1.      Staff will immediately enlist the help of additional staff if they are available and intervene to protect the health and safety of persons involved. 

2.      Staff will redirect persons to discontinue the behavior and/or physically place themselves between the aggressor(s) using the least intrusive methods possible in order to de-escalate the situation.

3.      If the aggressor has a behavior plan in place, staff will follow the plan as written in addition to the methodologies that may be provided in the Coordinated Service and Support Plan Addendum.

4.      Staff will remove the person being aggressed towards to an area of safety.

5.      If other least restrictive alternatives were ineffective in de-escalating the aggressors’ conduct and immediate intervention is needed to protect the person or others from imminent risk of physical harm, staff will follow the Policy and Procedure on Emergency Use of Manual Restraint and/or staff will call “911.”

6.      If the ordinary operation of the program is disrupted, staff will manage the situation and will return to the normal routine as soon as possible.

7.      To the extent possible, staff will visually examine persons served for signs of physical injury and document any findings.

8.      If the conduct results in injury, staff will provide necessary treatment according to their training.

 

G.     Sexual activity between persons served involving force or coercion

1.      Staff will follow any procedures as directed by the Individual Abuse Prevention Plans and/or Coordinated Service and Support Plan Addendums, as applicable.

2.      Staff will immediately intervene in an approved therapeutic manner to protect the health and safety of the persons involved if there is obvious coercion or force involved, or based on the knowledge of the persons involved, that one of the persons may have sexually exploited the other.

3.      If the persons served are unclothed, staff will provide them with a robe or other appropriate garment and will discourage the person from bathing, washing, changing clothing or redressing in clothing that they were wearing.

4.      Staff will leave the area where the sexual activity took place untouched if it is under the DAC’s control.

5.      Staff will call “911” in order to seek medical attention if necessary and inform law enforcement.

6.      To the extent possible, staff will visually examine persons served for signs of physical injury and document any findings.

7.      If the incident resulted in injury, staff will provide necessary treatment according to their training.

 

 

Reporting incidents

A.     Staff will first call “911” if they believe that a person is experiencing a medical emergency that may be life threatening. In addition, staff will first call “911,” a mental health crisis intervention team for a person experiencing a mental health crisis, or a similar mental health response team or service when available and appropriate.

 

B.     Staff will immediately notify the Designated Coordinator and/or Designated Manager that an incident or emergency has occurred and follow direction issued to them and will document the incident or emergency on an Incident and Emergency Report and any related program or health documentation. Each Incident and Emergency Report will contain the required information as stated in the Policy and Procedure on Reviewing Incidents and Emergencies.

 

C.     When the incident or emergency involves more than person served, the DAC and staff will not disclose personally identifiable information about any other person served when making the report to each person and/or legal representative and case manager unless the DAC has the consent of the person and/or legal representative.

 

D.     The Designated Coordinator and/or Designated Manager will maintain information about and report incidents to the legal representative or designated emergency contact and case manager within 24 hours of an incident occurring while services are being provided, within 24 hours of discovery or receipt of information that an incident occurred, unless the DAC has reason to know that the incident has already been reported, or as otherwise directed in the person’s Coordinated Service and Support Plan and/or Coordinated Service and Support Plan Addendum. 

 

E.      A report will be made to the MN Office of the Ombudsman for Mental Health and Developmental Disabilities and the Department of Human Services Licensing Division within 24 hours of the incident, or receipt of the information that the incident occurred, unless the DAC has reason to know that the incident has already been reported, by using the required reporting forms. These forms include Death Reporting Form, Serious Injury Form, and Death or Serious Injury Report FAX Transmission Cover Sheet. Incidents to be reported include:

1.      Serious injury as determined by MN Statutes, section 245.91, subdivision 6.

2.      Death of a person served.

 

F.      Verbal reporting of an emergency use of manual restraint will occur within 24 hours of the occurrence. Further reporting procedures will be completed according to the Policy and Procedure on Emergency Use of Manual Restraint which includes the requirements of reporting incidents according to MN Statutes, sections 245D.06, subdivision 1 and 245D.061.

 

G.     Within 24 hours of reporting maltreatment, the DAC will inform the case manager of the nature of the activity or occurrence reported and the agency that received the report. The DAC and staff will follow the applicable policy and procedure on reporting maltreatment for vulnerable adults or minors, as applicable.