Incident/Accident/Death

PM FORM 7.4.1

INCIDENT/ACCIDENT/DEATH REPORT FORM

INSTRUCTIONS:

1.  Complete ALL sections of this form. Information provided must be either typed or printed.

2.  Incidents, accidents, and deaths occurring in facilities licensed by the ADHS Office of Behavioral Health Licensure (OBHL) must be verbally reported to OBHL (602-364-2595) within 24 hours and reported in writing to OBHL (FAX 602-324-5872) within 5 working days.

3.  Incidents, accidents, and deaths, including those occurring during a T/RBHA or provider sponsored prevention activity affecting non-enrolled persons must be reported in writing to the TRBHA within 48 hours, or two business days.

4. A verbal report should be made to the case manager and parent/guardian (Tribal Social Service case worker) within 24 hours.

5. Submit written report via email to: (not to the GRBHS case manager) using the secure system Zixmail at https://web1.zixmail.net/s/login?b=grhc; Please submit via fax only if secure email is not working; call or email to announce that an IAD has been faxed; Gila River BHS QI Dept. Fax: (520) 550-6040

Gila River BHS QI Dept. Phone: (520) 550-6207, 6202, or 6377

T/RBHA NAME:
Gila River BHS / GSA:
4
Provider Name:
/ Behavioral Health License#: / Subclass:
/ Tracking ID#:
Behavioral Health Facility Address & Phone #:
Date Submitted to Gila River BHS (same as Date Received; date MUST be affixed): /

TYPE OF REPORT: Check all that apply

Death (All Must Be Reported)
Suicide
Homicide (victim)
Accident
Natural
Other (specify):
Unknown
All INCIDENTS INCLUDING THOSE OCCURRING DURING A T/RBHA OR PROVIDER SPONSORED PREVENTION ACTIVITY AFFECTING non-ENROLLED PERSONS: / THE FOLLOWING VIOLATIONS ARE REPORTED REGARDLESS IF THEY OCCURRED IN AN OBHL LICENSED FACILITY, OR NOT.
Medication Error(s)
Adverse Reaction to Medication
Physical Abuse/Allegation
Neglect
Emotional Abuse/Allegation
Verbal Abuse/Allegation
Sexual Abuse/Allegation
Suicide Attempt
Self-Inflicted Injury
Physical Injury
Food Poisoning
Injury as the result of personal or mechanical restraint.
Illness Requiring Treatment
Referral was made to:
Law Enforcement Report #
Abuse or neglect reported to Adult Protective Services
Abuse of neglect reported to Child Protective Services / Member Rights Violation/Allegation:
Discrimination
Neglect
Exploitation
Coercion
Manipulation
Retaliation for submitting complaint to authorities
Threat of discharge/transfer for punishment
Treatment involving denial of food
Treatment involving denial of opportunity to sleep
Treatment involving denial of opportunity to use toilet
Use of restraint or seclusion as retaliation
Unauthorized Absence from Residential Agency/ Inpatient Treatment Program/Level IV Transitional Agency
Suspected or alleged criminal activity / Discovery that a client, staff member, or employee has a communicable disease (listed in R9-6-202)
Other (specify):
Assigned Member OR NON-ENROLLED BEHAVIORAL HEALTH RECIPIENT Involved in Incident:
Name: AHCCCS ID: CIS ID:
Age: DOB: Gender: Female Male
Check All That Apply: Title XIX Title XXI Non-Title XIX/XXI
(one per line) COT SMI SA GMH Child DDD CMDP
Current Diagnosis: Axis I Axis II Axis III
Date of Last Visit to Psychiatrist: Date of Last Visit to Nurse: Date of Last Visit to Case Manager

Name of Assigned/Non-enrolled person:

Incident DETAILS:
Date & Time of Incident:
Address & Location:
Provider Name:
Provider Address:
Program Admission Date:
Name of Case Manager & Phone Number:
Date Incident Reported to Provider:
INDIVIDUALS WHO OBSERVED INCIDENT (including staff and witnesses):
Name: / Relationship to enrolled/non-enrolled person:
Address: / Phone#:
Name: / Relationship to enrolled/non-enrolled person:
Address: / Phone#:
Name: / Relationship to enrolled/non- enrolled person:
Address: / Phone #:
Description of incident
Describe the events leading up to and including the incident:
Describe the person’s physical and behavioral health condition before the incident:
Describe the person’s physical and behavioral health condition after the incident:

Name of Assigned/Non-enrolled person:

Document any actions taken and/or recommendations for action to prevent a similar incident from occurring in the future:
Preparer’s Name and Title Phone #:
______
Preparer’s Signature Date Signed:
Please select from drop-down list: Submitted Electronically, Provider has signed copyIAD Report Faxed to Gila River BHS (QI contacted)
COMPLETE THIS SECTION FOR ALL INCIDENTS/ACCIDENTS REQUIRING MEDICAL SERVICES
Who provided immediate attention:
Who provided medical services:
Date and time of medical services:
Emergency Room (ER) services:
YES / NO / Name of ER:
Hospital admission:
YES / NO / Name of hospital:
CLINICAL DIRECTOR’S OR DESIGNEE’S REVIEW OF INCIDENT: Review all relevant information and documentation in the member’s record. Ascertain objectively what occurred and document any action you have taken and or recommendations that you have made. NOTE: This section MUST be completed and signed in order for the incident to be processed.
CLINCAL DIRECTOR OR DESIGNEE NAME, CREDENTAL & TITLE
______CLINCAL DIRECTOR OR DESIGNEE SIGNATURE
Please select from drop-down list: Submitted Electronically, Provider has signed copyIAD Report Faxed to Gila River BHS (QI contacted) / PHONE#:
DATE SIGNED:
Date Submitted to Gila River BHS (this same date MUST be affixed to pg. 1 as well): //
Notification MADE, CHECK ALL THAT APPLY:
Tribal/Regional Behavioral Health Authority (T/RBHA) / Date / Time of Notification
Office of Behavioral Health Licensure (OBHL) / Date / Time of Notification
Arizona Center for Disability Law (ACDL) / Date / Time of Notification
Police / Date / Time of Notification
Adult Protective Services (APS) / Date / Time of Notification
Child Protective Services (CPS) / Date / Time of Notification
Gila River BHS QI Dept. (Written report) / Date / Time of Notification
Behavioral Health Case Management (phone call) / Date / Time of Notification
DES Case Worker / Date / Time of Notification
Parent / Guardian (TSS Case Worker) / Date / Time of Notification
Probation / Date / Time of Notification
Other (Specify): / Date / Time of Notification

Last Revision Date: 08/10/2012

Effective Date: 12/31/2012