DEATH AND INCIDENT REPORTING

DEATH AND INCIDENT REPORTING

POLICY    The Incident & Death Report Manual developed by the NC Department of Health & Human Services-Division of MH/DD/SAS will be used as the established procedure for handling all critical client incidents or death reporting at The Ship Group Community Services The Ship Group Community Services trains all new-hires in critical incident and death reporting procedures and provides on-going, in-service education for all employees. The Internal Incident/Investigation Form shall be used internally to investigate critical and non-critical incidents. The Client Death Determination will also be used as supporting documentation if a client dies while receiving services through The Ship Group Community Services.

Death Reporting

The death of a client may stem from of variety of factors such as accidents, illness, natural or unnatural disasters, violence / physical force, homicide, or suicide. The purpose of this policy is to assist the paraprofessional staff as they take control of the situation and report the death of a client.

DEFINITIONS

“Accident” means an unexpected, unnatural or irregular event contributing to a client’s death and includes but is not limited to medication errors, falls, fractures, choking, elopement (escape, run away from or abscond), exposure, poisoning, drowning, burns or thermal injury, electrocution, misuse of equipment, motor vehicle accidents, and natural disasters.

“Abuse” means the infliction of mental or physical pain or injury by other than accidental means, or unreasonable confinement, or the deprivation by an employee of services that are necessary to the mental or physical health of the client. Temporary discomfort that is a part of an approved treatment plan or use of an emergency procedure shall not be considered abuse.

“Neglect” means the failure to provide the care or services necessary to maintain the mental or physical health and well-being of the client.

“Immediately” means at once, at or near the present time, without delay.

“Violence” means physical force exerted for the purpose of violating, damaging, abusing or injuring.

REVIEW OF FATALITIES

For the purposes of this section, agencies licensed in accordance with G.S. 122C, Articles 2, state agencies operating in accordance with G.S. 122C Article 4, Part 5 and inpatient psychiatric units of hospitals licensed under G.S. 131E shall report client deaths to DFS. Client deaths occurring in agencies not licensed by DFS with G.S. 122C Articles 2 or state agencies:

• The Ship Group Community Services will review all fatalities of active clients who are being served at the time of death.

• Notification of all fatalities (deaths) must be sent to the LME immediately by the QP

• A written report shall be presented to the referring agency within 24 hours.

The Ship Group Community Services will report client deaths to the Division of Agency Services. Upon learning of the death of a client currently receiving services, The Ship Group Community Services will file a report in accordance with GS 122C-31 and these Rules. Learning of a death is when any staff obtains information that the death occurred. A written notice containing the below listed information will be made immediately for deaths occurring within seven (7) days of physical restraint. A written notice containing the below noted information under Paragraph (d) of this Rule shall be made within three (3) days of any death resulting from violence, accident, suicide, or homicide. Written notice may be submitted by facsimile or electronic mail. If the reporting agencies do not have the capability to submit a written notice immediately, the information noted below can be reported by telephone following the same time requirements under Subparagraph (b) and (c) of this rule until such time the written notice can be submitted. Notice will include at least the following:

• Reporting agency: name, address, county, license number, (if applicable), Medicare/Medicaid provider number (if applicable), the name of the agency’s director and telephone number, name and title of person preparing the report, first person to learn of death, and the first staff to receive the report of death, agency’s telephone number, and date and time report prepared.

• Client information: name, client record number, Medicare/Medicaid number (if applicable), date of birth, age, height, weight, race, sex, competency, admitting diagnosis, primary or secondary mental illness, developmental disability or substance abuse diagnosis, primary/secondary physical illness/conditions diagnosed prior to death, date(s) of last two medical examinations (if known), date of most recent admission to a State Operated psychiatric, developmental disability or substance abuse agency(if known), and date of most recent admission to an acute care hospital for physical illness(if known).

• Circumstances of death: place and address where decedent died, date and time death was discovered, physical location decedent was found, cause of death (if known), whether or not decedent was restrained at the time of death or within seven days of death and if so, a description of the type of restraint and its usage. Whether or not decedent was in seclusion at the time of death or within seven days of death and if so, a description of the seclusion episode(s), and a description of the events surrounding the death, and

• Other information: list of authorities such as law enforcement or the County Department of Social Services that has been notified, has investigated, or is in the process of investigating the death or events related to the death.

The Ship Group Community Services , Inc will submit a written report using a form pursuant to GS 122C-31F. The Ship Group Community Services will provide, fully and accurately, all information sought on the form. If unable to obtain any information sought on the form or such information is not yet available, an explanation will be made on the form. In addition, The Ship Group Community Services shall:

• Notify the appropriate division specified in Rule .0301 of this section, immediately whenever it has reason to believe that information provided may be erroneous, misleading, or otherwise unreliable.

• Submit to the appropriate division on Rule .0301 of this section, immediately after it becomes available, any information required by this Rule that was previously unavailable.

• Provide, upon request by the appropriate division, other information the agency obtains regarding the death, including, but not limited to, death certificates, autopsy reports, and reports by other authorities.

With regard to any client death under circumstances described in GS 130A-383, The Ship Group Community Services will notify the appropriate law enforcement authorities so the medical examiner of the county in which the body is found can be notified. Documentation of such notification will be maintained by The Ship Group Community Services and will be made available for review by the appropriate division upon request.

In deaths not under the jurisdiction of the medical examiner, The Ship Group Community Services will notify the decedent’s next-of-kin, or other individual authorized according to GS 130A-398 that an autopsy may be requested as designated in GS 130A-389.

If the circumstances surrounding any client death reveal reason to believe that one or more clients in the agency may be abused, neglected, or exploited and in need of protective services, The Ship Group Community Services will initiate the procedures outlined in GS 7B-3, Article 3.

The clinical professional staff person upon notification or realization that a death may have occurred, regardless of the situation surrounding the death, should:

1. Immediately secure the area, but not disturb anything;

2. Make sure the other clients are safe, as applicable;

3. Call the Program Director and / or On-Duty Administrator (Clinical or Medical Director);

4. Call the police, the police will call the Medical Examiner;

5. Call the Qualified Professional and Program Coordinator;

6. Record the time, date and how the information was received on the Client Death Determination Form;

7. Do not notify the client’s legally responsible person

The paraprofessional staff person shall remain calm and prepare to convey any information known about the situation to law enforcement. If the client is transported to the hospital, the paraprofessional staff, the Program Director and / or the On-Duty Administrator will accompany the client. The staff shall thoroughly and accurately complete the Internal Incident and Investigation Form, immediately.

If a pronouncement of death is made by a medical professional, but the circumstances surrounding the death are not immediately known, without delay the Client Death Determination Form shall be faxed to the Secretary of DHHS, the Department of Social Services, the Local Management Entity (LME) and the sponsoring agency, providing the information you have at that time. The Program Director must also thoroughly and accurately complete the DHHS Critical Incident and Death Report and submit it to the Secretary as soon as the rest of the details are known, no later than 8 hours after the initial documentation.

If at the pronouncement of death, abuse, neglect, or injury by a client or staff is suspected, the Executive Director and Program Director shall individually conduct confidential interviews with all clients and/or staff involved. The client shall have the right to request the presence of a person of their choosing to be present for the interview process. The Executive Director will conduct interviews and have them record anything they may have witnessed. If the client or other staff were not witnesses, they too shall write and endorse a statement to that effect.

The Program Director/Clinical Director/Medical Director shall be responsible for the completion of all documentation and channeling information to the LME, police, the required agencies, the county Department of Social Services or department heads. The North Carolina Health Care Personnel Registry Initial Investigation Form and the five-day follow-up form shall be completed by the Program Director and submitted to the NCHCPR within the time constraints provided.

If an agency staff is alleged to have abused, neglected or injured the deceased client, whether substantiated or not, the staff shall be suspended by the Program Director or the On-duty Administrator from direct care services until the agency investigation is complete. If a client is alleged to have abused a client the same process shall be followed, however, steps shall be taken to suspend services until the incident(s) are investigated.

The suspended employee will make no contact to the agency or with the client for any reason; this constitutes a breach of confidentiality and program policy and may result in charges being filed with law enforcement.

It is the responsibility of The Ship Group Community Services to provide for and protect every client in our program. Program staff are expected to report to administration any observed acts of abuse, neglect, exploitation or violence toward any client in our program, without delay or fear. All reports will be kept confidential; however, law enforcement investigations or medical necessity may impede confidentiality.

All allegations of abuse, neglect, or violence shall be reported to the County Division of Social Services who will also investigate on behalf of the other clients of the agency.

INCIDENT REPORTING

INTERPRETATION

An incident as defined is 10A NCAC 27G .0103(b)(32), is “any happening which is not consistent with the routine operation of The Ship Group Community Services or the routine care of a client and that is likely to lead to adverse effects upon a client.” The Incident Manual as established by NCDHHS is comprehensive detailing the steps necessary when making reports regarding:

1. Client death

2. Seclusion, isolated time-out and restraint

3. Client Injury due to:

a. Aggressive behavior

b. Self-harm

c. Trip or fall

d. Auto Accident

e. Other unknown cause

4. Abuse of client

5. Neglect of client

6. Exploitation of client

7. Wrong dose of medication

8. Wrong medication

9. Wrong time (over 1hr. from prescribed time)

10. Missed dose or medication refusal

11. Suicidal Behavior

12. Sexual Behavior

13. Aggressive or destructive acts that result in reports to law enforcement

14. Suspension from services

15. Expulsion from services

16. Fire

17. Search and seizure

18. Breaches of confidentiality

19. Safety Hazards

Any employee observing, being involved in, or being informed of an unusual or adverse incident or medication error will complete a Critical Incident/Death Report Form-DHHS Form QM-02. The form will be completed providing complete and concise descriptions of the event (only the observed facts should be documented), actions taken and client statements and status regarding the event.

All incidents will be verbally reported to the Clinical Director and Program Director within 1 hour of the occurrence, incidents resulting in the death of a client shall be reported immediately. Incident Reports will be filed by month in the administrative office, but will not be filed in the client records. Incident files will not be maintained in the Corporate Office.

The written report will be given to the Program Director within 24 hours of the incident or at the beginning of the very next working day, except when the report involves the death of a client; death is reported immediately. Incidents where public law enforcement is involved, accident, death, injury or illness to the client, or property damage above $100.00, or where items 1-13 & 16 are involved require a written Critical Incident and Death Report.

Items 14, 15, 17, 18, and 19 above, are not considered critical however, documentation of such incidents by the paraprofessional staff is required; the documented incidents will be reviewed and signed by the Program Director, and reviewed by the Client Rights and QI Committee. The Program Director will conduct an internal investigation within 24 hours of the incident, using the Internal Investigation Form.

The Program Director, when appropriate, will also complete the Supervisor’s Section of the 24-Hour Initial Report and follow the guidelines for submitting a copy of the report to the North Carolina Health Care Personnel Registry (NCHCPR) for reports of abuse, neglect, misappropriation of client or program funds, etc. The five-day report shall be submitted as soon as the investigation is complete. A copy shall be submitted to the county Department of Social Services.

The Program Director has responsibility for maintaining audit ready records of all client Incident and Reports.

All Incident/Critical Incident/Death Reports will be reviewed during the quarterly Quality Assurance Committee Meeting and by the Client Rights Committee at their quarterly meeting.

Sample | Level I Internal Investigation / Incident Report