Powerpoint Incident Reporting

Care and Compliance Group, Inc • 800.321.1727 • www.careandcompliance.com

Incident Reporting

Instructor Guide

UPDATED JUNE 22, 2011

INSTRUCTOR GUIDE: INCIDENT REPORTING

Overview

Incident reports are required by state regulations and when done properly can be an important part of your risk management strategies. This course will address when to report an incident, what to document, how to fill out an incident report form, and when multiple reports might be necessary.

Video(s) “Incident Reporting” (20 minutes)

Special Supplies Have sample incident report forms available for students to complete. Mark them in bold letters “PRACTICE INCIDENT REPORTS” to avoid them being mistaken for actual incident reports.

Learning Objectives

1. What is a reportable incident? 2. When to complete an incident report 3. Who incident reports are submitted to 4. How incident reports are maintained in our facility

QUIZ: INCIDENT REPORTING

Name: Date: 1. An incident report should be filed if first aid was given to an individual. a. True b. False 2. Which of the following would require that an incident report be filed?

a. A fall b. An injury c. A medical emergency d. All of the above

3. An incident report should outline what happened and to who, interventions taken and the condition of the person? a. True b. False 4. Generally speaking, which of the following mandate how incident reports are

handled?

a. Federal law b. State regulation c. Your facility

5. Incident reports may generally be kept in the resident’s chart with all of their other

documentation. a. True b. False

6. Which of the following statements is appropriate when dealing with incident reports?

a. When in doubt, do not fill out an incident report b. When in doubt, fill one out

7. If you suspect but have no proof that abuse has taken place, you should not

complete an incident report until proof is acquired. a. True b. False 8. You enter the resident’s room and find Mary on the floor. She states that she fell out

of bed. Which of the following statements should be included in the incident report?

a. “Mary fell out of her bed” b. “I found Mary on the floor next to her bed” c. “Mary said she fell out of her bed” d. b & c

9. Mary claims that the money in her dresser drawer was stolen while she was in the

dining room. She stated that while returning from dinner, she saw a caregiver leaving her room. Should an incident report be filed?

a. Yes b. No

10. When completing an incident report, include everything you think may have

happened leading up to the incident, even if you did not witness these things.

a. True b. False

QUIZ KEY: INCIDENT REPORTING 1. An incident report should be filed in first aid was given to an individual. a. True b. False 2. Which of the following would require that an incident report be filed?

a. A fall b. An injury c. A medical emergency d. All of the above

3. An incident report should outline what happened and to who, interventions taken and the condition of the person? a. True b. False 4. Generally speaking, which of the following mandate how incident reports are

handled?

a. Federal law b. State regulation c. Your facility

5. Incident reports may generally be kept in the resident’s chart with all of their other

documentation. a. True b. False

6. Which of the following statements is appropriate when dealing with incident reports?

a. When in doubt, do not fill out an incident report b. When in doubt, fill one out

7. If you suspect but have no proof that abuse has taken place, you should not

complete an incident report until proof is acquired. a. True b. False 8. You enter the resident’s room and find Mary on the floor. She states that she fell out

of bed. Which of the following statements should be included in the incident report?

a. “Mary fell out of her bed” b. “I found Mary on the floor next to her bed” c. “Mary said she fell out of her bed” d. b & c

9. Mary claims that the money in her dresser drawer was stolen while she was in the

dining room. She stated that while returning from dinner, she saw a caregiver leaving her room. Should an incident report be filed?

a. Yes b. No

10. When completing an incident report, include everything you think may have

happened leading up to the incident, even if you did not witness these things.

a. True b. False

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Care and Compliance Group, Inc • 800.321.1727 • www.careandcompliance.com

Incident Reporting

Learner Workbook

UPDATED JUNE 22, 2011

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INTRODUCTION Reporting incidents that occur in our assisted living and residential care communities is required by state regulations. When done properly it can be an important part of your risk management strategies. In this course we will discuss when to report an incident, what to document, how to fill out an incident report form, and when multiple reports might be necessary. Basics of Incident Reporting It is important as a care provider to handle the incident properly and do all you can to ensure the well being of the individual resident you are caring for. The following are key steps when completing an incident report.

1. Know your Community policies on incident reporting (Read and understand your policies and procedures. If you have any questions, be sure to ask your supervisor as he/she is here to help.)

2. Know your state regulations on incident reporting (State regulations will usually

dictate: when, how, and whom the incident report should be submitted to.)

3. Determine if an incident report is necessary (Remember, “When in doubt, fill one out.”)

4. Speak with your supervisor to ensure Community specific policies are followed (You should not be afraid to talk to your supervisor about an incident. Your supervisor’s responsibility is to assist you through the process.)

5. Use the correct form (Generally, there is a designated form for incident reporting. Ask your supervisor to provide a copy of your Community Incident Report Forms for you to review.)

6. Fill out the form completely (Do not leave blank spaces in the report.)

7. Stick to the facts (No opinions or perceptions, just facts!)

8. Include the interventions used (Document what you did to help the resident you are caring for. Include if you provided first aid, called 9-1-1, etc.)

9. Send the report to the right people (Verify whom to report to with your policies, regulations and supervisor. Remember the incident report is a confidential report and must be kept separate from the resident’s individual records. Many state require the incident report be submitted to the licensing offices.)

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10. File the report properly in the Community according to Community policy (You

should file the report in a confidential file, outside of the individual’s care record.)

As you follow these steps of incident reporting keep in mind the purpose of reporting an incident is to provide the best possible care for each of our residents as we follow our Community policies and state regulations. What is a reportable incident? Reportable incidents may include but are not limited to:

• Falls

• Injuries

• Abuse/Alleged Abuse

• Medical Emergencies What does an incident report contain? Incident reports should contain the essential information regarding the incident. Questions should be answered such as: who, what, when, where, and how. Basic facts about incident reports include:

• What happened

• What interventions were put into action

• The condition of the resident

• Any outcomes from the incident An incident report is a different document than the resident’s individual record. Incident reports are confidential and not meant for public record. Incident reports should contain information that describes the circumstances of the incident and what actions were taken to ensure effective care for the resident.

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Information typically found in an incident report includes:

• Name of the person(s) affected/involved

• Date and time of incident

• Description of what happened

• Where the incident occurred

• Your interventions

• Condition of the person

• Follow-up needed

• Name and signature

When filling out an incident report you will want to write legibly, in blue or black ink, and sign and date entries using your professional title. If you make an error, be sure to correct the error by drawing a single line through inaccurate material, write the word error and initial it. Never use white out or scratch the error! Be specific and concise. As a care provider you will need to be familiar with your Community’s policies and procedures along with your state regulations regarding incident reporting. Let us now discuss our Community specific policy and out state specific regulations on completing an incident report.

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Incident Report Regulations Ask your supervisor to provide a copy of your state regulations for reference during this course. Questions you will need to ask when completing an incident report include:

• Who is authorized to complete the report?

• Who is the report submitted to?

• What are the time frames for completing the report? Each state may have different requirements for these above questions. There may also be various forms you will need to complete depending on the type of incident that occurred. In some cases your care setting may require two incident reports to be completed following a reportable incident; one report that is submitted to state and other representatives and a separate confidential report that is maintained for internal investigation purposes. If you do maintain two such reports it is important to consult with your legal counsel regarding procedures necessary to keep the internal report confidential.

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When to complete an incident report Generally speaking, if you are not sure if you should complete an incident report, go ahead and fill one out. Always follow your Community policies and procedures. Incidents that in most cases would require an incident report include any threat to an individual. For example:

• An incident that threatens the health of a resident

• An incident that threatens the safety of a resident

• An incident that threatens the welfare of a resident

• An incident that violates the rights of a resident

Types of injuries which warrant an incident report to be completed include:

• Cuts

• Bruises

• Broken bones

• Trauma

Incident reports need to be completed for various health related problems. For example:

• Medical emergencies

• Heart attack or stroke

• Medication error

• Hospitalization

• Emergency first aid received

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An incident report must also be completed if a violation or suspicion of violation of a resident’s rights occurs. All care staff are mandated reporters and must report the following: Both actual and suspected

• Physical abuse

• Emotional abuse

• Neglect

• Financial abuse

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Check for Understanding: Incident Reporting

When must an incident report be completed?

A. Whenever there is a threat to the resident’s health, safety, welfare, or rights. B. After any injury, such as: cuts, bruises, broken bones, or trauma. C. Whenever there are health related problems, such as: heart attack, stroke,

medication errors, hospitalization, or first aid was performed on resident. D. All of the above

Explain your answer:

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SAMPLE INCIDENT REPORT FORM The following is a sample incident report form. Ask your supervisor to provide a copy of your Community’s Incident Report Form to reference during the exercise below.

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Practice Incident Reporting Take the time to practice filling out an incident report. Be sure to clearly mark “sample report” in order to avoid mistaking for an actual report filed. Choose an incident scenario that would warrant an incident report and fill out the report. Remember, you do not want to speculate on what you think might have happened. Only document the facts. Do not forget to include intervention you implemented to assist the resident.