Cart
Courses: 0

Total: $00.00

Incident Reporting Ohio 1 Hour Back to Course Index

 

 


    

INCIDENT REPORTING

 

Introduction

In a health care facility, such as a hospital, recovery center, nursing home, or assisted living, an incident report is a form that is filled out in order to record details of an unusual event that occurs at the facility, such as an injury to a patient or client.

images-2What is the Purpose of an Incident Report?

Incident reports should not be used to blame or punish staff but rather to learn areas of concern and better approaches to client/patient safety. 

Incident Reports are used to communicate information to other people and to document significant events within individual records and as required by state standards.  People often use the information obtained from incident reports when formulating plans or profiles, to develop support strategies, and when making decisions.

Consequently, it is extremely important for the content of the Incident Report to reflect clear information in a factual, unbiased manner to avoid passing along opinions and judgments.  What a staff person has to say concerning an incident is essential to other people who are trying to understand what has happened and why it occurred.

Staff should re-read the reports that they have written prior to submitting them to ensure that they are legible, have been completed properly and that the report truly states what the writer has intended to convey.  All sections of the report must be completed (avoid leaving blanks).  Incident Reports are legal documents that the individual may view, their guardian, designee, or legal representative, and may be utilized by courts.  Be sure to use the full name of staff or providers when referencing them in a report; initials of staff/providers are not sufficient.

imgres-7When Should An Incident Report Be Written?

Staff should prepare an incident report to document unusual and/or significant events or emergencies involving individuals who receive services and/or support.  Examples of such events include but are not limited to the following:

imgres-1

 

 

 

  • Injury to an individual
  • Aggressive behavior directed at others
  • Self-abusive behavior
  • Endangering or threatening others
  • Serious illness and/or hospitalization
  • Imminent death or death
  • Property destruction
  • Serious disruptive situation while in the community
  • Illegal or unusual problematic behavior
  • Being victimized by another individual who receives services
  • Any incident involving the police, fire department, ambulance, etc.
  • Any time someone has physically intervened with an individual when such intervention is not in accordance with an approved behavioral treatment plan
  • Any time an individual is involved in an automobile accident while receiving services
  • Being a victim of a crime reported to a law enforcement agency;
  • Being incarcerated (in jail or prison for at least one overnight stay);
  • Others should note significant accomplishments or other positive changes.

If you are unsure about whether or not to complete an incident report, complete one.

If an incident involves the behavior/injury of more than one individual, separate reports are necessary.  Be sure that you do not include confidential information about others on an individual’s report.

images-1Writing an Incident Report

First and most important, don’t delay.  Obtain the proper documentation as soon as possible and fill out the details as clearly as you can remember.  Make sure to outline:

-The name and address of the organization.

-The concern in one or two pages, including:

Who – Who was involved in the incident?

What – What exactly happened?

When – When did the event occur; note the specific date and time.imgres-5

Where – Where did the situation occur?

How – How was the situation or event handled?

Safety – Also, remember, if the situation warrants it, implement a safety plan and note what you did to keep everyone safe.

 

Each person writing an Incident Report should consider the following:

Cause of Incident:

Make every attempt to provide only factual information.  Even if the actual cause of an incident remains unknown after you have attempted to determine it, you should give as much information as you have concerning what happened before the event/during the event, as this may provide a clue to the reader.  If you did not witness the incident or event, you might still write an Incident Report; however, be sure to state that the information is based on what was reported to you and by whom it was reported.

Language:

Describe the incident in concrete, behavioral terms.  Do not use generalities…be specific.  Review your report to verify that you have not used judgmental terminology or left unanswered questions.  It is best to prepare an Incident Report immediately following the incident while the facts are still clear.  However, staff may still be emotionally involved at that time, so it may be helpful to have another person review the report prior to it being submitted.

Please remember that your description of the incident is what other people will rely on to obtain information concerning the individual and the incident.  It is important that your report does not convey negative images of you or the individual when a more neutral one should be conveyed.  Examples: stating someone stole food out of the refrigerator when the individual took food out of the refrigerator.  Your report has the ability to influence others, so it is important that it is properly prepared and provides a factual accounting of the incident.

Reliability of your observation:

Would other people seeing or hearing the incident agree with the account that you have written?  If another person was involved in the incident or witnessed it, consult with that person to ensure that the report concurs with that person’s observations.  When writing your report, use terms that are specific and clearly describe the behavior that occurred.  For example, don’t use generalities such as aggressive/upset/agitated, state the behavior that you observed that made you believe the person was being aggressive, was upset, or agitated.

Objectivity: When writing your report, be sure that you have not allowed an earlier situation or prior information to influence your perception of the current incident.  You are writing your report as a recorder, not as a judge.  Consequently, be sure that your report is free from judgmental statements, sarcasm, or condescending comments.

 

imgres-9Ohio Incident Reporting

 

 

 

Ohio Forms
• Alcohol and Other Drugs Major Unusual Incident Notification- Form: OMHAS-7133
• Certified Community Mental Health Agency Notification of Incident- Form: DMHAS-0484
• Licensed Residential Mental Health Provider Reportable Incident- Form: DMHAS-0484a
• Private Psychiatric Hospital Reporting- From: DMHAS-0177
These forms can also be found on the Ohio Department of Mental Health and Addiction Services website at www.mha.ohio.gov

Ohio Administrative Code Rule 5122-26-13
Incident Notification and Risk Management
Policies For the Operation of Mental Health Services Agencies

This administrative code rule establishes standards to ensure the prompt and accurate notification of certain prescribed incidents. It also requires the provider to review and analyze all incidents so that it might identify and implement corrective measures designed to prevent recurrence and manage risk.  *For the full verbiage please see Ohio Code.

“Incident” means an event that poses a danger to the health and safety of clients or staff and visitors of the provider, and is not consistent with routine care of persons served or routine operation of the provider.

“Reportable Incidents” (which may include “major unusual incidents” as referred to in O.R.C. 5119.36), are incidents that involve clients and include:

  • deaths
  • serious bodily injuries
  • alleged criminal acts
  • alleged physical or sexual abuse
  • neglect
  • any adverse reaction of a client to a life threatening degree due to an administered drug
  • medication errors likely to result in serious consequences to a client
  • any life threatening situation

“Death” includes deaths for any active client either on or off the Provider’s premises.  “Death” also includes any death of Provider staff, contract staff, students or volunteers on the Provider’s premises while performing tasks for the program or participating in program activities, including work performed off site.

“Six month reportable incident” means an incident type of which limited information must be reported to the department. A six month reportable incident is not the same as a reportable incident.

 “Six month incident data report” means a data report which must be submitted to the department.

The provider should develop an incident reporting system to include a mechanism for the review and analysis of all reportable incidents such that clinical and administrative activities are undertaken to identify, evaluate, and reduce risk to clients, staff, and visitors. The provider should identify in policy other incidents to be reviewed and analyzed.

An incident report shall be submitted in written form to the provider’s executive director or designee within twenty-four hours of discovery of a reportable incident.

As part of the provider’s performance improvement process, a periodic review and analysis of reportable incidents, and other incidents as defined in the provider’s policy, should be performed. This should include a review of all incident reports received from class two and class three residential facilities.

The provider should maintain an ongoing log of its reportable incidents for departmental review.

Any person who has knowledge of any instance of abuse or neglect, or alleged or suspected abuse or neglect of:

Any child or adolescent, should immediately notify the county children’s services board, the designated child protective agency, or law enforcement authorities or

An adult age sixty and over, shall immediately notify the appropriate county department of jobs and family services authorities.

Each provider shall submit reportable incidents and six month reportable incidents as defined:

All certified and/or licensed contract agencies should forward each Reportable Incident I to Ohio MHAS within twenty-four hours of its discovery, exclusive of weekends and holidays.

The six month incident data report must be submitted according to the following schedule:
• Six month incident data report for the period of January first to June thirtieth shall be submitted no later than July thirty-first of the same year; and
• Six month incident data report for the period of July first to December thirty-first shall be submitted no later than January thirty-first of the following year

Each reportable incident should be documented as required by the department. The information should include identifying information about the provider, date, time and type of incident, and client information that has been de-identified pursuant to the HIPAA privacy regulations, [45 C.F.R. 164.514(b)(2)], and 42 CFR Part B, paragraph 2.22., if applicable.

Only one incident form per event occurrence and identify each incident report category should be sent, if more than one, and include information regarding all involved clients, staff, and visitors.

If, after submitting a reportable incident to the department, a provider learns that an additional incident report category in addition to that which was already submitted is associated with the same event occurrence, the provider shall either amend the original report or submit a new incident report including only the new incident category and information.

(H) The department may initiate follow-up and further investigation of a reportable incident and six month reportable incidents, as deemed necessary and appropriate, or may request such follow-up and investigation by the provider, regulatory or enforcement authority, or the county community board.

Ohio Administrative Code Rule 5122-30-16
Incident Notification and Risk Management
Licensing of Residential Facilities  *For the full verbiage please visit Ohio Code.

This rule establishes standards to ensure the prompt and accurate notification of certain prescribed incidents that occur in residential facilities.

“Incident” means an event that poses a danger to the health and safety of clients or staff and visitors of the provider, and is not consistent with routine care of persons served or routine operation of the provider.

“Reportable Incidents” (which may include “major unusual incidents” as referred to in O.R.C. 5119.36), are incidents that involve clients and include:

  • deaths
  • serious bodily injuries
  • alleged criminal acts
  • alleged physical or sexual abuse
  • neglect
  • any adverse reaction of a client to a life threatening degree due to an administered drug
  • medication errors likely to result in serious consequences to a client
  • any life threatening situation

“Six month reportable incident” means an incident type of which limited information must be reported to the department. A six month reportable incident is not the same as a reportable incident.

 “Six month incident data report” means a data report which must be submitted to the department.

The operator should develop an incident reporting system to include a mechanism for the review and analysis of all reportable incidents such that clinical and administrative activities are undertaken to identify, evaluate, and reduce risk to residents, staff, and visitors. The operator shall identify in policy other incidents to be reviewed.

An incident report should be submitted in written form to the operator or designee within twenty-four hours of discovery of the incident.

A periodic review and analysis of reportable incidents, and other incidents as defined in facility policy, should be performed. This should include any action taken by the operator, as appropriate, including actions recommended by the provider from which the resident receives services. This should be incorporated as part of the facility’s performance improvement process, as applicable.

The operator shall maintain an ongoing log of its reportable incidents for departmental review.

Any person who has knowledge of any instance of abuse or neglect, or alleged or suspected abuse or neglect of any child or adolescent should immediately notify the county children’s services board, the designated child protective agency, or law enforcement authorities.

Any person who has knowledge of any instance of abuse, neglect, or exploitation; alleged or suspected abuse, neglect, or exploitation; or of an alleged crime against an elderly person, shall immediately notify the appropriate law enforcement and county department of jobs and family services authorities.

Any person who has knowledge of an alleged crime against a child or adolescent, including a crime allegedly committed by another child or adolescent, should immediately notify law enforcement authorities.

Each operator should submit reportable incidents and six month reportable incidents to the department.

Class one facilities provide accommodations, supervision, personal care services, and mental health services for one or more unrelated adults with mental illness or one or more unrelated children or adolescents with severe emotional disturbances. Each operator of a class 1 facility shall submit reportable incidents and six month reportable incidents as defined by and according to the schedule included in appendix A to this rule.

(1) “Emergency/Unplanned Medical Intervention” means treatment required to be performed by a licensed medical
doctor, osteopath, podiatrist, dentist, physician’s assistant, or certified nurse practitioner, but the treatment
required is not serious enough to warrant or require hospitalization. It includes sutures, staples,
immobilization devices and other treatments not listed under “First Aid”, regardless of whether the treatment
is provided in the facility, or at a doctor’s office/clinic/hospital ER, etc. This does not include routine medical
care or shots/immunizations, as well as diagnostic tests, such as laboratory work, x-rays, scans, etc., if no
medical treatment is provided.
(2) “First Aid” means treatment for an injury such as cleaning of an abrasion/wound with or without the application
of a Band-aid, application of a butterfly bandages/Steri-Strips™, application of an ice/heat pack for a bruise,
application of a finger guard, non-rigid support such as a soft wrap or elastic bandage, drilling a nail or
draining a blister, removal of a splinter, removal of a foreign body from the eye using only irrigation or swab,
massage, drinking fluids for relief of heat stress, eye patch, and use of over-the-counter medications such as
antibiotic creams, aspirin and acetaminophen. These treatments are considered first aid, even if applied by a
physician. These treatments are not considered first aid if provided at the request of the resident and/or to
provide comfort without a corresponding injury.
(3) “Hospitalization” means inpatient treatment provided at a medical acute care hospital, regardless of the length
of stay. Hospitalization does not include treatment when the individual is treated in and triaged through the
emergency room with a discharge disposition to return to the community, or admission to psychiatric unit.
(4) “Injury” means an event requiring medical treatment that is not caused by a physical illness or medical
emergency. It does not include scrapes, cuts or bruises which do not require medical treatment.
(6) “Sexual Conduct” means as defined by Section 2907.01 of the Ohio Revised Code, vaginal intercourse between
a male and female; anal intercourse, fellatio, and cunnilingus between persons regardless of sex; and, without
privilege to do so, the insertion, however slight, of any part of the body or any instrument, apparatus, or other
object into the vaginal or anal opening of another. Penetration, however slight, is sufficient to complete
vaginal or anal intercourse.
(7) “Sexual Contact” means as defined by Section 2907.01 of the Ohio Revised Code, any touching of an
erogenous zone of another, including without limitation the thigh, genitals, buttock, pubic region, or, if the
person is a female, a breast, for the purpose of sexually arousing or gratifying either person.

Suicide The intentional taking of one’s own life by a resident.
Suicide Attempt Intentional action by a resident with the intent of taking one’s own life, and is
either a stated suicide attempt or clinically determined to be so, regardless of
whether it results in medical treatment.
Self-Injurious Behavior Intentional injury caused by a resident to oneself that is neither a stated suicide
attempt, or clinically determined to be so, which requires emergency/unplanned
medical intervention or hospitalization, and which happens on the grounds of the
facility or during the provisions of care or treatment, including during facility offgrounds events.
Homicide by Resident The alleged unlawful killing of a human being by a resident.
Natural Death Death of a resident without the aid of inducement of any intervening
instrumentality, i.e. homicide, suicide or accident
Accidental Death Death of a resident resulting from an unusual and unexpected event that is not
suicide, homicide or natural, and which happens on the grounds of the facility or
during the provisions of care or treatment, including during facility off-grounds
events.
Physical Abuse Allegation of staff action directed toward a resident of hitting, slapping, pinching,
kicking, or controlling behavior through corporal punishment or any other form
of physical abuse as defined by applicable sections of the Revised or
Administrative Code.
Sexual Abuse Allegation of staff action directed toward a resident where there is sexual contact
or sexual conduct with the resident, any act where staff cause one or more other
persons to have sexual contact or sexual conduct with the resident, or sexual
comments directed toward a resident. Sexual conduct and sexual contact have the
same meanings as in Section 2907.01 of the Revised Code.
Neglect Allegation of a purposeful or negligent disregard of duty imposed on an
employee by statute, rule, organizational policy, or professional standard and
owed to a resident by that staff member.
Defraud Allegation of staff action directed toward a resident to knowingly obtain by
deception or exploitation some benefit for oneself or another or to knowing
cause, by deception or exploitation, some detriment to another.

Involuntary Termination
Without Appropriate
Resident Involvement
Discontinuing services to a resident without informing the resident in advance of
the termination, providing a reason for the termination, and offering a referral to
the resident. This does not include situations when a resident discontinues
services without notification, or the facility documents it was unable to notify the
resident due to lack of address, returned mail, lack of or non-working phone
number, etc.
Sexual Assault by Nonstaff, Including a Visitor,
Resident or Other
Any allegation of one or more of the following sexual offenses as defined by
Chapter 2907 of the Revised Code committed by a non-staff against another
individual, including staff, and which happens on the grounds of the facility or
during the provisions of care or treatment, including during facility off-grounds
events: Rape, sexual battery, unlawful sexual conduct with a minor, gross sexual
imposition, or sexual imposition.
Physical Assault by Nonstaff, Including Visitor,
Resident or Other
Knowingly causing physical harm or recklessly causing serious physical harm to
another individual, including staff, by physical contact with that person, which
results in an injury requiring emergency/unplanned medical intervention,
hospitalization, or death and which happens on the grounds of the facility or
during the provision of care or treatment, including during facility off-grounds
events.
Medication Error Any preventable event while the medication was in the control of the health care
professional or resident, and which resulted in permanent resident harm,
hospitalization, or death. Such events may be related to professional practice,
health care products, procedures, and systems, including prescribing; order
communication, product labeling, packaging, and nomenclature; compounding;
dispensing; distribution; administration; education; monitoring; and use.
Adverse Drug Reaction Unintended, undesirable or unexpected effect of prescribed medications that
resulted in permanent resident harm, hospitalization, or death.

Theft of Allegation of theft of prescribed medication under the control of or stored by the
Medication facility.

Subcategory [check one] 1. Employee theft
2. Resident theft
3. Other/Unknown theft

Medical Events Impacting The presence or exposure of a contagious or infectious medical illness within an
Facility Operations facility, whether brought by staff, resident, visitor or unknown origin, that poses a
significant health risk to other staff or residents in the facility, and that requires
special precautions impacting operations. Special precautions impacting operations
include medical testing of all individuals who may have been present
in the facility, when isolation or quarantine is recommended or ordered by the
health department, police or other government entity with authority to do so,
and/or notification to individuals of potential exposure. Special precautions
impacting operations does not include general isolation precautions, i.e. suggesting
staff and/or residents avoid a sick individual or vice versa, or when a disease may
have been transmitted via consensual sexual contact or sexual conduct.
Temporary Relocation of
Residents
Some or all of the residents must be moved to another unit, residential facility or
community location for a minimum period of at least one night due to:
Subcategory (check one) 1. Fire
2. Disaster (flood, tornado, explosion, excluding snow/ice)
3. Failure/Malfunction (gas leak, power outage, equipment failure
4. Other (name)
Involuntary Discharge Involuntary discharge of a resident unless the facility is no longer able to meet the
resident’s care needs; the resident presents a documented danger to other residents, staff or visitors; or the monthly charges have not been paid for more than thirty days.
Involuntary discharge includes discharging a resident after the resident unexpectedly
vacates the facility for more than forty-eight hours without any notification to staff, and the monthly (or daily) charges for the days the resident is missing have been paid.
Missing/Unaccounted for Prescribed medication under the control of or stored by facility which is missing Medication or unaccounted for, that is not believed to be a result of theft.

Inappropriate Use of
Seclusion or restraint
Subcategory (check all that
apply)
Seclusion or restraint utilization that is not clinically justified, or mechanical
restraint or seclusion employed without the authorization of staff permitted to
initiate/order mechanical seclusion or restraint
1. Seclusion
2. Mechanical restraint
3. Physical restraint, including transitional hold
Total Minutes The total number of minutes of the seclusion or restraint.
Use of Seclusion/Restraint
by a Facility without Prior
Notification that the Facility
Permits the Use of Seclusion
or Restraint
Subcategory (check one)
Inappropriate Restraint
Techniques and other Use
of Force
Subcategory (check all that
apply)
Use of seclusion or restraint without notification to the Department in accordance
with paragraph (A)(1)(e) of rule 5122-25-03 or paragraph (A)(1)(e) of rule 5122-
25-01 of the Administrative Code of a facility’s intent to utilize seclusion or
restraint.
1. Seclusion
2. Mechanical restraint
3. Physical restraint, including transitional hold
Staff utilize one or more of the following methods/interventions prohibited by
paragraph (D)(2) of rule 5122-26-16 of the Administrative Code:
1. Behavior management interventions that employ unpleasant or aversive
stimuli such as: the contingent loss of the regular meal, the contingent
loss of bed, and the contingent use of unpleasant substances or stimuli
such as bitter tastes, bad smells, splashing with cold water, and loud,
annoying noises
2. Any technique that restricts the resident’s ability to communicate
3. Any technique that obstructs vision
4. Any technique that obstructs the airways or impairs breathing, including
placing a cloth or other item over an individual’s mouth or nose.
5. Use of mechanical restraint on a resident under age 18
6. A drug or medication that is used as a restraint to control behavior or
restrict the resident’s freedom of movement and is not a standard
treatment or dosage for the resident’s medical or psychiatric condition or
that reduces the resident’s ability to effectively or appropriately interact
with the world around him/her
7. The use of handcuffs or weapons such as pepper spray, mace, nightsticks,
or electronic restraint devices such as stun guns and tasers
Seclusion/Restraint Related
Injury to Resident
Injury to a resident caused, or it is reasonable to believe the injury was caused by
being placed in seclusion/restraint or while in seclusion/restraint, and first aid or
emergency/unplanned medical intervention was provided or should have been
provided to treat the injury, or medical hospitalization was required. It does not
include injuries which are self-inflicted, e.g. a resident banging his/her head, performed by staff, or injuries caused by another resident, e.g. a resident hitting
another resident.
Subcategory (check one) 1. Injury requiring first aid
2. Injury requiring unplanned/emergency medical intervention
3. Injury requiring hospitalization
Seclusion/Restraint Related
Death
Death of a resident which occurs while a resident is restrained or in seclusion,
within twenty-four hours after the resident is removed from seclusion or restraint,
or it is reasonable to assume the resident’s death may be related to or is a result of
seclusion or restraint
Subcategory (check one) 1. Death during seclusion or restraint
2. Death within twenty-four hours of seclusion or restraint
3. Death related to or result of seclusion or restraint

Seclusion A staff intervention that involves the involuntary confinement of a resident alone
in a room where the resident is physically prevented from leaving.
Age 17 and Under The aggregate total number of all episodes of seclusion and aggregate total
minutes of all seclusion episodes.
Age 18 and Over The aggregate total number of all episodes of seclusion and aggregate total
minutes of all seclusion episodes.
Mechanical Restraint A staff intervention that involves any method of restricting a resident’s freedom
of movement, physical activity, or normal use of his or her body, using an
appliance or device manufactured for this purpose.
Age 18 and Over The aggregate total number of all episodes of mechanical restraint and aggregate
total minutes of all mechanical restraint episodes.
Physical Restraint
excluding Transitional
Hold
A staff intervention that involves any method of physically (also known as
manually) restricting a resident’s freedom of movement, physical activity, or
normal use of his or her body without the use of mechanical restraint devices
Age 17 and Under The aggregate total number of all episodes of physical restraint and aggregate
total minutes of all physical restraint episodes, excluding transitional hold.
Age 18 and Over The aggregate total number of all episodes of physical restraint and aggregate
total minutes of all physical restraint episodes, excluding transitional hold.
Transitional Hold A staff intervention that involves a brief physical (also known as manual)
restraint of a resident face-down for the purpose of quickly and effectively
gaining physical control of that resident, or prior to transport to enable the
resident to be transported safely.
Age 17 and Under The aggregate total number of all episodes of transitional hold and aggregate total
minutes of all transitional hold episodes.
Age 18 and Over The aggregate total number of all episodes of transitional hold and aggregate total
minutes of all transitional hold episodes.
Seclusion/Restraint Related
Injury to Staff Injury to staff caused, or it is reasonable to believe the injury was caused as a
result of placing an individual in seclusion/restraint, and first aid or
emergency/unplanned medical intervention was provided or should have been
provided to treat the injury, or medical hospitalization was required. It does not
include injuries which occur prior to, or are the rationale for, placing an individual
in seclusion or restraint.
Subcategory (check one) 1. Injury requiring first aid
2. Injury requiring emergency/unplanned medical intervention
3. Injury requiring hospitalization

FORM

Class two facilities provide accommodations, supervision, and personal care services.  Class three facilities provider room and board for five or more unrelated adults with mental illness.  Each operator of a class 2 and class 3 facility shall submit reportable incidents as defined by appendix C to this rule.

(1) “Emergency/Unplanned Medical Intervention” means treatment required to be performed by a licensed medical
doctor, osteopath, podiatrist, dentist, physician’s assistant, or certified nurse practitioner, but the treatment
required is not serious enough to warrant or require hospitalization. It includes sutures, staples,
immobilization devices and other treatments not listed under “First Aid”, regardless of whether the treatment
is provided in the facility, or at a doctor’s office/clinic/hospital ER, etc. This does not include routine medical
care or shots/immunizations, as well as diagnostic tests, such as laboratory work, x-rays, scans, etc., if no
medical treatment is provided.
(2) “First Aid” means treatment for an injury such as cleaning of an abrasion/wound with or without the application
of a Band-aid, application of a butterfly bandages/Steri-Strips™, application of an ice/heat pack for a bruise,
application of a finger guard, non-rigid support such as a soft wrap or elastic bandage, drilling a nail or
draining a blister, removal of a splinter, removal of a foreign body from the eye using only irrigation or swab,
massage, drinking fluids for relief of heat stress, eye patch, and use of over-the-counter medications such as
antibiotic creams, aspirin and acetaminophen. These treatments are considered first aid, even if applied by a
physician. These treatments are not considered first aid if provided at the request of the resident and/or to
provide comfort without a corresponding injury.
(3) “Hospitalization” means inpatient treatment provided at a medical acute care hospital, regardless of the length
of stay. Hospitalization does not include treatment when the individual is treated in and triaged through the
emergency room with a discharge disposition to return to the community, or admission to psychiatric unit.
(4) “Injury” means an event requiring medical treatment that is not caused by a physical illness or medical
emergency. It does not include scrapes, cuts or bruises which do not require medical treatment.
(6) “Mechanical Restraint” means a staff intervention that involves any method of restricting a resident’s freedom
of movement, physical activity, or normal use of his or her body, using an appliance or device manufactured
for this purpose.

(7) “Physical Restraint”, also known as “manual restraint”, means a staff intervention that involves any method of
physically (also known as manually) restricting a resident’s freedom of movement, physical activity, or
normal use of his or her body without the use of mechanical restraint devices.
(8) “Seclusion” means a staff intervention that involves the involuntary confinement of a resident alone in a room
where the resident is physically prevented from leaving.
(9) “Sexual Conduct” means as defined by Section 2907.01 of the Ohio Revised Code, vaginal intercourse between
a male and female; anal intercourse, fellatio, and cunnilingus between persons regardless of sex; and, without
privilege to do so, the insertion, however slight, of any part of the body or any instrument, apparatus, or other
object into the vaginal or anal opening of another. Penetration, however slight, is sufficient to complete
vaginal or anal intercourse.

(10) “Sexual Contact” means as defined by Section 2907.01 of the Ohio Revised Code, any touching of an
erogenous zone of another, including without limitation the thigh, genitals, buttock, pubic region, or, if the
person is a female, a breast, for the purpose of sexually arousing or gratifying either person.
(11) “Transitional hold” means a staff intervention that involves a brief physical (also known as manual) restraint
of a resident face-down for the purpose of quickly and effectively gaining physical control of that resident, or
prior to transport to enable the resident to be transported safely.

The following lists and defines each event category which must be reported per incident in accordance with
paragraph (G)(2) of rule 5122-30-16 of the Administrative Code.
Category Reportable Incident Definition
Suicide The intentional taking of one’s own life by a resident.
Suicide Attempt Intentional action by a resident with the intent of taking one’s own life, and is
either a stated suicide attempt or clinically determined to be so, regardless of
whether it results in medical treatment.
Self-Injurious Behavior Intentional injury caused by a resident to oneself that is neither a stated suicide
attempt, or clinically determined to be so, which requires emergency/unplanned
medical intervention or hospitalization, and which happens on the grounds of the
facility or during the provisions of care or treatment, including during facility offgrounds events.
Homicide by Resident The alleged unlawful killing of a human being by a resident.
Natural Death Death of a resident without the aid of inducement of any intervening
instrumentality, i.e. homicide, suicide or accident
Accidental Death Death of a resident resulting from an unusual and unexpected event that is not
suicide, homicide or natural, and which happens on the grounds of the facility or
during the provisions of care or treatment, including during facility off-grounds
events.

Physical Abuse Allegation of staff action directed toward a resident of hitting, slapping, pinching,
kicking, or controlling behavior through corporal punishment or any other form
of physical abuse as defined by applicable sections of the Revised or
Administrative Code.
Sexual Abuse Allegation of staff action directed toward a resident where there is sexual contact
or sexual conduct with the resident, any act where staff cause one or more other
persons to have sexual contact or sexual conduct with the resident, or sexual
comments directed toward a resident. Sexual conduct and sexual contact have the
same meanings as in Section 2907.01 or the Revised Code.
Neglect Allegation of a purposeful or negligent disregard of duty imposed on an
employee by statute, rule, organizational policy, or professional standard and
owed to a resident by that staff member.
Defraud Allegation of staff action directed toward a resident to knowingly obtain by
deception or exploitation some benefit for oneself or another or to knowing
cause, by deception or exploitation, some detriment to another.

Involuntary Termination
Without Appropriate
Resident Involvement
Discontinuing services to a resident without informing the resident in advance of
the termination, providing a reason for the termination, and offering a referral to
the resident. This does not include situations when a resident discontinues
services without notification, or the facility documents it was unable to notify the
resident due to lack of address, returned mail, lack of or non-working phone
number, etc.
Sexual Assault by Nonstaff, Including a Visitor,
Resident or Other
Any allegation of one or more of the following sexual offenses as defined by
Chapter 2907 of the Revised Code committed by a non-staff against another
individual, including staff, and which happens on the grounds of the facility or
during the provisions of care or treatment, including during facility off-grounds
events: Rape, sexual battery, unlawful sexual conduct with a minor, gross sexual
imposition, or sexual imposition.
Physical Assault by Nonstaff, Including Visitor,
Resident or Other
Knowingly causing physical harm or recklessly causing serious physical harm to
another individual, including staff, by physical contact with that person, which
results in an injury requiring emergency/unplanned medical intervention,
hospitalization, or death and which happens on the grounds of the facility or
during the provision of care or treatment, including during facility off-grounds
events.
Medication Error Any preventable event while the medication was in the control of the health care
professional or resident, and which resulted in permanent resident harm,
hospitalization, or death. Such events may be related to professional practice,
health care products, procedures, and systems, including prescribing; order
communication, product labeling, packaging, and nomenclature; compounding;
dispensing; distribution; administration; education; monitoring; and use.

Adverse Drug Reaction Unintended, undesirable or unexpected effect of prescribed medications that
resulted in permanent resident harm, hospitalization, or death.
Medical Events Impacting
Facility Operations
The presence or exposure of a contagious or infectious medical illness within an
facility, whether brought by staff, resident, visitor or unknown origin, that poses a
significant health risk to other staff or residents in the facility, and that requires
special precautions impacting operations. Special precautions impacting
operations include medical testing of all individuals who may have been present
in the facility, when isolation or quarantine is recommended or ordered by the
health department, police or other government entity with authority to do so,
and/or notification to individuals of potential exposure. Special precautions
impacting operations does not include general isolation precautions, i.e.
suggesting staff and/or residents avoid a sick individual or vice versa, or when a
disease may have been transmitted via consensual sexual contact or sexual
conduct.

Temporary Relocation of
Residents
Some or all of the residents must be moved to another unit, residential facility or
community location for a minimum period of at least one night due to:
Subcategory (check one) 1. Fire
2. Disaster (flood, tornado, explosion, excluding snow/ice)
3. Failure/Malfunction (gas leak, power outage, equipment failure
4. Other (name)
Unauthorized Use of
Restraint or Seclusion
Ohio Administrative Code rule 5122-30-17 prohibits the use of seclusion and
restraint in a Class 2 and Class 3 residential facility.
Subcategory (check one) 1. Seclusion
2. Mechanical restraint
3. Physical restraint
4. Transitional hold
Total Minutes The total number of minutes of the restraint or seclusion.
Involuntary Discharge Involuntary discharge of a resident unless the facility is no longer able to meet the
resident’s care needs; the resident presents a documented danger to other
residents, staff or visitors; or the monthly charges have not been paid for more
than thirty days. Involuntary discharge includes discharging a resident after the
resident unexpectedly vacates the facility for more than forty-eight hours without
any notification to staff, and the monthly (or daily) charges for the days the
resident is missing have been paid.
Inappropriate Discharge Discharge of a resident without providing thirty days prior written notice for
termination of residency except in an emergency when the resident presents a
documented danger to other residents, staff or visitors.
Missing/Unaccounted for Prescribed medication under the control of or stored by facility which is missing
Medication or unaccounted for, that is not believed to be a result of theft.
Theft of Medication Allegation of theft of prescribed medication under the control of or stored by the
facility.
Subcategory [check one] 1. Employee theft
2. Resident theft
3. Other/Unknown theft

 

(H) Each reportable incident shall be documented as required by the department. The information shall include identifying information about the provider, date, time and type of incident, and client information that has been de-identified pursuant to the HIPAA privacy regulations, [45 C.F.R. 164.514(b)(2)], and 42 CFR Part B, paragraph 2.22., if applicable.

(1) The operator shall file only one incident form per event occurrence and identify each incident report category, if more than one, and include information regarding all involved residents, staff, and visitors.

(2) The operator shall forward each reportable incident to the department and to each of the following within twenty-four hours of its discovery, exclusive of weekends and holidays:

(a) The board of residence and the board whose service district includes the facility, for individuals with mental illness; and,

(b) The provider from which the mental health resident is receiving services, if applicable.

(3) The operator shall notify the resident’s parent, guardian or custodian, if applicable, within twenty-four hours of discovery of a reportable incident, and document such notification.

(a) Notification may be made by phone, mailing, faxing or e-mailing a copy of the incident form, or other means according to facility policy and procedures.

(b) When notification does not include sending a copy of the incident form, the facility must inform the parent, guardian or custodian, of his/her right to receive a copy, and forward a copy within twenty-four hours of receiving a request for a copy. The facility shall document compliance with the provisions of this paragraph.

(I) Each operator of a class 1 facility shall submit a six month incident data report to the department. utilizing the form that is in appendix B of this rule.

Each operator must submit the six month incident data report according to the following schedule:

(1) The six month incident data report for the period of January first to June thirtieth of each year shall be submitted no later than July thirty-first of the same year.

(2) The six month incident data report for the period of July first to December thirty-first of each year shall be submitted no later than January thirty-first of the following year.

(J) The department may initiate follow-up and further investigation of a reportable incident and six month reportable incidents, as deemed necessary and appropriate, or may request such follow-up and investigation by the residential facility, a regulatory or enforcement authority, or the board.

In the case of class one facilities, a board shall have the authority to inspect any facility which has residents for which the board is providing funding for community mental health services.

 

(A) The use of seclusion, mechanical restraint, and physical restraint, including transitional hold, shall not be permitted in any facility, except a class one facility as defined in division (B) of section 5119.34 of the Revised Code, which meets all of the requirements of rules 5122-26-16 to 5122-26-16.2 of the Administrative Code.

(B) The use of seclusion, mechanical restraint, and physical restraint, including transitional hold, in facilities in which they are not permitted pursuant to paragraph (A) of this rule must be reported to the department as a major unusual incident.

 

 

Each facility in which one or more of the residents has a physical disability shall make reasonable accommodations including but not limited to:

(A) Making the facility readily accessible to and usable by persons with a physical disability, and

(B) Providing all communications to residents in a manner that is accessible and understandable to the resident; this may include, but not be limited to: readers, interpreters, braille, large print, or providing appropriate telecommunication relay services (TRS). A TRS is a telephone service that allows persons with hearing or speech disabilities to place and receive telephone calls, such services include but are not limited to text to speech relay and signing to speech relay.

 

 

Mental Health and Addiction Services Incident Reporting 

Web Enabled Incident Reporting System (WEIRS)

WEIRS is an online incident reporting system for use by community behavioral health providers,  residential facilities (non-substance Use Disorder), and private psychiatric hospital providers to report both INCIDENTS and Six Month Reportable Data.

One person from an organization serves as the “external administrator”, which is the individual who is authorized to assign User Roles (level of access privileges) to other staff.  The External Administrator may register up to eight certification or license numbers for one account. 

images-9The Joint Commission on the Accreditation of Healthcare Organizations

  • In 1995, hospital-based surveillance was mandated by the Joint Commission because of the perception that incidents resulting in harm were frequently occurring.  The Joint Commission employs the term sentinel event in lieu of a critical incident and defines it as follows:
  • An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function.  The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
  • As one component of its Sentinel Event Policy, The Joint Commission created a Sentinel Event Database.  The database accepts voluntary reports of sentinel events from member institutions, patients and families, and the press.  The particulars of the reporting process are left to the member healthcare organizations.  The Joint Commission also mandates that accredited hospitals perform root cause analysis of important sentinel events.  Data on sentinel events are collated, analyzed, and shared through a Web site, an online publication, and its newsletter, Sentinel Event Perspectives.

images-10How Do You Submit An Incident Report

  • Your organization should have its form to use for incident reporting.  If not, create one with the required information included:
  • Organization Name
  • Organization Address
  • Reporters Name
  • Incident Date
  • Incident Narrative

The preferred method for submitting a patient safety concern to The Joint Commission is through our online submission form as it allows for more direct, timely receipt and review of your concerns.

By policy, The Joint Commission cannot accept copies of medical records, photos or billing invoices and other related personal information. These documents will be shredded upon receipt.

 

Conclusion

Patient safety is a priority.  Documentation of patient care holds the healthcare team members to professional accountability and demonstrates the quality care you have given.  When the unforeseen happens, and sometimes it does, the reporting of incidents can help identify will potential issues are.  We need to focus on a blameless reporting atmosphere where healthcare providers feel safe making reports.  Speak up if you have questions regarding your workplace or see areas of concern.