SELF REPORTED INCIDENTS

1. SELF REPORTED INCIDENTS How to Manage Them Effectively Leigh Grindley, RN, NHA Regional Vice President North Region LaVie Management Services

2. 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

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

4. 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?

5. 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?

6. Hot Liquid Burns How do you decrease the likelihood of receiving an IJ for a hot liquid burn?

7. 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?

8. 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?

9. 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?

10. 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?

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

12. 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?

13. 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?

14. What do I do if I have a Self Reported Incident • Ensure that the resident/residents are safe. • As soon as practicable, complete a thorough investigation to determine what occurred. Interview the resident, room mate, other residents, staff who witnessed the event. • Assess the environment and equipment. • Do not leave a stone unturned!!!

15. What do I do if I have a Self Reported Incident (cont.) • Review the policy and determine if the policy was being followed? • Interview staff to determine if they followed the policy. • Review the chart in detail to determine if the event was avoidable or unavoidable? • Be critical of your process to determine the areas of risk? • Identify the root cause of the event

16. What do I do if I have a Self Reported Incident (cont.) • Identify interventions to keep the event from recurring and ensure they are implemented. • Take credit for the interventions implemented in the chart; assessment, care plan etc • Report to the State within 24 hours of the event occurring. Send the 5 day report to the State within 5 working days. • Review through your RM/QI Committee Meeting.

17. How do I keep my other residents safe • Identify the other residents at risk and reassess them accordingly. • Take credit for interventions implemented in the Residents charts; assessment and care plan. • Provide training to relevant staff immediately. Do not let staff work until they have been trained. • Develop a Risk Management Quality Improvement Monitoring tool to ensure compliance.

18. 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.

19. ROOT CAUSE ANALYSIS • WHY, WHY, WHY, WHY,WHY • Interventions are band aids. If you don’t 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.

20. ROOT CAUSE ANALYSIS • Why did the kitchen aide not know that she was supposed to clean it? • Because the Kitchen Supervisor had not trained her to do so. • Why had the Kitchen Supervisor not trained her to clean the microwave. • Because there were no cleaning schedules in place to clean the microwave. • What is the root cause of the microwave not being cleaned • 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.

21. 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?

22. 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

23. 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.

24. 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.

25. 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: < 4%

26. 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%)

27. 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%)

28. 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.