SELF REPORTED INCIDENTS

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SELF REPORTED INCIDENTS

• How to Manage Them Effectively
• Leigh Grindley, RN, NHA
• Regional Vice President
• North Region
• LaVie Management Services

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Objectives

• Identification of risks
• Do you have your systems in place?
• What to do when you have an SRI
• Root cause analysis
• 4 step process and RM/QI Committee and monitoring
• Statistics
• Summary

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ELOPEMENTHow do you decrease the likelihood of
receiving an IJ for an elopement in your facility?
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Elopement Prevention

• How do you assess your residents to determine if
  they are at risk for elopement on admission and
  ongoing?
• What is your system and criteria for identifying
  residents at risk?
• How do you alert your staff that residents are at
  risk?
• What systems do you have in place to keep your
  resident safe wander guard system, increased
  supervision, door alarms etc?

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Elopement Prevention (cont.)

• How confident are you that the facility building
  structure is going to alert you if your residents
  attempt to leave the facility?
• How confident are you that your staff are
  monitoring the location of the residents at risk?
• How confident are you that your staff know your
  policy and procedure?
• How are you monitoring compliance?
• Have you reviewed through your RM/QI Committee?

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Hot Liquid Burns

• How do you decrease the likelihood of receiving
  an IJ for a hot liquid burn?

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Hot Liquid Burn Prevention

• How do you assess your residents on admission and
  ongoing to determine if they are at risk?
• In the event that you find that the resident is
  at risk, what systems have you implemented to
  keep your residents safe?
• What adaptive equipment or protective equipment
  are you providing for the residents at risk?
• How are you monitoring the safety of, and how are
  you supervising the resident?

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Hot Liquid Burn Prevention (cont.)

• What first aide equipment is in place in the
  event that the resident does spill hot liquid on
  their skin?
• Do your staff know which residents are at risk
  and how to protect the resident from a hot liquid
  burn?
• Do your staff know how to provide first aide if
  there is a burn?
• How are you monitoring compliance with your
  policy?
• Have you reviewed in your RM/QI Committee Meeting?

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FULL CODE VERSUS DNR

• What system do you have in place for assessment
  of your residents code status?
• What system do you have in place for identifying
  the residents code status?
• Do you have an emergency cart available to your
  Nurses to utilize in the case of an emergency?
• Do all staff know where it is located?

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FULL CODE VERSUS DNR (cont.)

• Is there an emergency cart checklist, is the cart
  ready to use and is it being checked daily by the
  midnight shift?
• Do your Nurses know how to perform CPR and have
  they been trained?
• Does the Nurse understand his/her role when
  performing CPR on a resident who is a full code?
• How confident are you that your staff can manage
  a code?
• How are you monitoring compliance?
• Have you reviewed through your RM/QI Committee?

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Falls

• How do you decrease the likelihood of receiving a
  G level citation for a fall with injury?

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Fall Prevention

• What system do you have in place to determine if
  a resident is at risk for falls on admission and
  ongoing?
• If a resident is at risk what interventions are
  you implementing to decrease the likelihood of
  the resident falling?
• How do you determine if the interventions are in
  place?
• How do your staff know what the interventions are?

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Fall Prevention (cont.)

• Do you have a system for identifying residents at
  risk?
• Does your staff know what the system is and which
  residents are at risk?
• How do you know if your staff are following the
  facility policy?
• How are you ensuring compliance?
• Have your reviewed in your RM/QI Committee
  Meeting?

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What do I do if I have a Self Reported Incident

1. Ensure that the resident/residents are safe.
2. As soon as practicable, complete a thorough
   investigation to determine what occurred.
   Interview the resident, room mate, other
   residents, staff who witnessed the event.
3. Assess the environment and equipment.
4. Do not leave a stone unturned!!!

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What do I do if I have a Self Reported Incident
(cont.)

1. Review the policy and determine if the policy was
   being followed?
2. Interview staff to determine if they followed the
   policy.
3. Review the chart in detail to determine if the
   event was avoidable or unavoidable?
4. Be critical of your process to determine the
   areas of risk?
5. Identify the root cause of the event

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What do I do if I have a Self Reported Incident
(cont.)

1. Identify interventions to keep the event from
   recurring and ensure they are implemented.
2. Take credit for the interventions implemented in
   the chart assessment, care plan etc
3. Report to the State within 24 hours of the event
   occurring. Send the 5 day report to the State
   within 5 working days.
4. Review through your RM/QI Committee Meeting.

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How do I keep my other residents safe

1. Identify the other residents at risk and reassess
   them accordingly.
2. Take credit for interventions implemented in the
   Residents charts assessment and care plan.
3. Provide training to relevant staff immediately.
   Do not let staff work until they have been
   trained.
4. Develop a Risk Management Quality Improvement
   Monitoring tool to ensure compliance.

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How do I keep my other residents safe (cont.)

• Initiate the implementation of the RM/QI Tool
  immediately and review compliance daily until you
  are satisfied that the system is in compliance.
• Conduct an RM/QI Committee meeting to review
  through your QA Process.
• Review the system with your team and review if
  plan is not working.
• Remember if the event is still occurring then
  your plan needs to be reviewed.

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ROOT CAUSE ANALYSIS

• WHY, WHY, WHY, WHY,WHY
• Interventions are band aids. If you dont
  identify the root cause the event will occur
  again.
• Example
• The microwave in the kitchen is dirty, why is it
  dirty?
• Because the Kitchen Aide did not clean it.
• Why did the kitchen aide not clean it?
• Because she did not know that she was supposed to
  clean it.

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ROOT CAUSE ANALYSIS

1. Why did the kitchen aide not know that she was
   supposed to clean it?
2. Because the Kitchen Supervisor had not trained
   her to do so.
3. Why had the Kitchen Supervisor not trained her to
   clean the microwave.
4. Because there were no cleaning schedules in place
   to clean the microwave.
5. What is the root cause of the microwave not being
   cleaned
6. The kitchen aide had not been trained to clean
   the microwave and the Kitchen Supervisor did not
   have a cleaning schedule in place, had not
   provided training to the kitchen aide and had not
   set expectations to clean the microwave.

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ROOT CAUSE ANALYSIS

• Mrs. Brown has been found on the floor five times
  in the past two weeks, what is the root cause?
• Mr. Jones fell forward out of his wheelchair at
  Bingo, what is the root cause?
• Mr. Smith hit Mr. Jones in the hallway, what is
  the root cause?

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AVOIDABLE VERSUS UNAVOIDABLE

• An event is considered avoidable if there is
  evidence that prior to the event occurring the
  resident was at risk and systems were not put in
  place at the time the risk was identified
• Example
• Resident attempts to open the door to the parking
  lot and there are no interventions put in place
  to prevent the event from occurring again.
• Resident is assessed as high risk on the Braden
  Scale and there are no interventions to decrease
  the likelihood of skin breakdown.
• Resident has a history of falls on admission and
  there is no evidence of interventions in place to
  prevent further falls

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AVOIDABLE VERSUS UNAVOIDABLE

• An event is considered unavoidable if at the
  time the event occurred, there is no evidence
  that the resident was at risk and the facility
  could not anticipate that the event would occur.

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AVOIDABLE VERSUS UNAVOIDABLE

• Example
• Resident ambulates independently and trips and
  falls. No previous evidence that would
  anticipate that this would happen.
• Resident goes out the door to the parking lot.
  No evidence that the resident was at risk nor had
  attempted this before this event.

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Falls Statistics North Region (10 facilities)

• 2010 1st Quarter 3.8
• 2010 2nd Quarter 3.7
• 2010 3rd Quarter 3.6
• 2010 4th Quarter 3.5
• 2011 1st Quarter 3.5
• 2011 2nd Quarter 3.4
• Goal lt 4

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Complaint Survey Statistics North Region (10
facilities)

• 2010 Complaint Surveys 16
• surveys with no citations 9 (56.25)
• 2011 Complaint Surveys 25 (up to June 2011)
• surveys with no citations 20 (80)

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Self Report Survey StatisticsNorth Region(10
facilities)

• 2010 SRI Surveys 16
• of surveys no citation 8 (50)
• 2011 SRI Surveys 26 (ytd June 2011)
• of surveys no citation 17 (65.38)

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Summary

• Be proactive not reactive.
• Effective assessment on admission to identify
  risks.
• Effective implementation of policy and
  procedures.
• Ongoing training of your staff.
• Administrator and DON completing regular rounds
  to oversee the implementation of policy and
  procedures.
• Root cause analysis when an event does occur.
• Is the event avoidable or unavoidable?
• Timely implementation of the 4 step process to
  ensure resident and other residents are safe.
• Utilization of your RM/QI Committee to review
  successful 4 step process implementation.
• Regular discussion with your Licensing Officer
  and Survey Monitor.