RESTORE POLICY AND PROCEDURE MANUAL

Section:
Quality of Care/Patient Safety / Policy Title:
Incident and Abuse Reporting / Policy Number:
Effective Date:
December 1, 2011 / Supersedes: / Page of
1 4

I. PURPOSE:

Restore’s goal is to continuouslyimprove safety and quality in the delivery of patient care and services. This policy establishes a method for the reporting and internal review ofany errors, incidents, and events, or potential for errors and incidents involving patients, staff, visitors, equipment, or supplies. This policy also establishes a process for collaborating with the Long Term Care (LTC) Facility on the obligation to reportto authoritiesany incidentswhere abuse, neglect, or criminal acts arereasonably suspected,in compliance with the Elder Justice Act of 2009 (EJA).

II. STANDARDS:

A. Restore requires all employees and agents to report any and all potential errors and incidents

occuring during the course of therapy delivery.

B. Restore will focus on improving the system of care delivery through teamwork and transparency.

C. Restore encourages a culture that minimizes individual blame where incidents and errors are

reported in good faith and our focus is on improving the safe delivery of care.

D. Restore expects all employees, without exception, to report any reasonable suspicion of abuse,

neglect, or other criminal acts against a resident in a LTC Facility.

III. DEFINITIONS:

A. Incident - Any occurrence, accident, error, or event that is not consistent with normal patient

care or routine operations which may result, or has resulted in harm or injury to a patient,staff, or

visitor. Incidents may include equipment malfunctions or supply failures andloss or damageto

property in addition to patient related processes.

B. Incident Report - An internal communication used as a tool for early identification of problems

and to review and investigate incidents for improvement of quality and safety. This document is

not part ofthe medical record.

C. Error - An act or omission that results in unexpected or unintended outcomes.

D. Harm - Injury (physical or psychological), disease, suffering, disability or death. It can be

considered unexpected if it is not related to the natural cause of the patient’s illness or condition.

E. Events -

1. Near Miss - Anything unusual that occurs. Any process variation which did not affect the

desired outcome and carries significant risk of a harmful outcome.

2. Hazardous Condition - Any external condition, outside the patient’s condition or disease,

with potentialto cause harm.

3. Adverse Reaction - An unexpected event or outcome associated with diet or medication.

4. Significant Event - An unusual, unexpected adverse outcome that may cause significant

harm/injury and result in a change in the patient’s level of care or monitoring.

5. Sentinel Event - An unexpected occurrence resulting in death, or serious bodily injury or any

process variation with the potential to resultin a serious adverse outcome.

F. Abuse - Knowlingly inflicting physical or psychological harm; refusing services necessary to

meet essential needsfor health and safety.

G. Serious Bodily Injury - an injury involving extreme physical pain, substantial risk of death, loss or

impairment of function of limb or organ, which results inthe need for external medical

interventions;harm/injury to a resident as a result of sexual abuse is considered serious bodily

injury and a criminal offense.

H. Neglect - failure of a caregiver to provide the goods or services necessary to maintain

health and safety.

I. Elder Justice Act of 2009 (EJA) - “Reporting Reasonable Suspicion of a Crime in a Long Term

Care (LTC) Facility”; requires any individual working within a LTC facility to report any

reasonable suspicion of a crime against a resident of a LTC facility and establishes reporting

timelines and establishes civil money penalties for delaying or neglecting to report.

IV. PROCEDURE:

A.Patient SafetyIncidents, Errors, Events

1. The resident should not be moved unnecessarily until physical condition has been

assessed.

2. Notify the Facility Administrator of the incident and comply with the Facility’s incident

reporting procedure.

3. Notify the Restore Rehab Director, Regional Operator, or Restore Office Manager and

provide a copy of the incident report, if possible.

4. Restore Management must be notified within 24 hrs or of a patient, equipment, or

facility incident, error, or event.

B. Suspected Abuse, Neglect, or other Criminal Acts

1. Under the EJA, reasonable suspicion of abuse, neglect, or other criminal acts must be

reported to law enforcement and the state survey agency as follows:

a.Where there is reasonable suspicion of abuse, neglect, or other criminal acts but no

serious bodily injuryhas occurred, the EJA requires notification to law enforcement

and the state survey agency within 24 hours from the time suspicion is formed.

b.Where there is reasonable suspicion of abuse, neglect, or other criminal acts and

serious bodily injury is noted and believed to be the result, the EJA requires a report

made to law enforcement and thestate survey agency immediately but no more than

two hoursfrom time a suspicion is formed.

c. Reports of abuse, neglect, or criminal acts against individuals in the LTC Facility should

be communicated to the Restore Compliance Officer immediately so that outside counsel

may be consulted.

d. Document all details of the reasons for suspicion, description of events, victim’s

appearance and condition, and names of all individuals who may have been within sight

when the event or suspicion occurred.

2. Restore employees are expected to notify the Facility Abuse Coordinator and cooperate with

Facility protocols, local law enforcement and State Survey Agents in investigating

any reports of abuse, neglect, or a crime against a resident, staff, or visitor to the Facility.

a. Failure to report or cooperate will result in disciplinary action up to and including

termination. (Refer to Human Resource Policy RTS 604 Section 6 Conduct; “Abuse

Reporting”)

C. Hazardous Condition,Equipment, or Supply Incidents

1. Secure or block the area/equipment/supply from use where there is risk of injury and follow

the Facility’s safety protocols.

2. Notify the Facility Administrator and Restore Rehab Director and continue to follow the

Facility’s safety protocols for the specific incident encountered, i.e., spills, equipment

breakdown, electrical malfunction, exposed wires, plumbing leaks, smoke, etc.

3. Notify the Restore Rehab Director, Regional Operator, or Office Manager within 24 hours of

a incident or error providing as much detail about the incident, equipment, or supply as

possible.

D. Report Tracking, Documenting, and Retention

1. Incident reports are reviewed by the Restore Office Manager and Compliance Officer.

2. The Compliance Officer and the Officer Manager will determine where to refer reports for

investigation.

3. Reports involving patient care, equipment, or therapy processes will be forwarded to the

Quality Assurance Committee.

4. Reports that appear to involve liability or risk of compensable event will be forwarded to

Restore outside counsel.

5. The Restore Office Manager will log incident reports and document the result of any

investigation or resolution.

6. The Restore Office Manager will maintain incidentreport files until scheduled for

destruction.