OADS - Evergreen Reportable Event Form.pdf

OADS – Evergreen Reportable Event Form Evergreen Reportable Event Form

Please Note: Required fields are marked with an asterisk (*).

Overview

* Person Name Required

* Reportable Event Create Date Required

* Program Required

* Person Adding Reportable Event Required

Report Details Report Title

* Incident Discovery Date (MM/DD/YYYY) Required

* Incident Start Date Required

* Incident Start Time Required

* Is this approximate? Required ☐ Yes ☐ No

Incident End Date Incident End Time

Is this approximate? ☐ Yes ☐ No

* Frequency of Occurrence (please choose one) Required

☐ First Occurrence ☐ Multiple Occurrences ☐ Continuing Pattern

* Describe Incident Details:

(Include a description of the 24 hours preceding and including the incident) Required

* Describe immediate response to incident:

(Include a summary of any actions taken in response to the incident) Required

* Incident Location Required

☐ Hospital ☐ Public Setting ☐ School ☐ Nursing Facility ☐ Stand Alone Hospice ☐ Assisted Living Facility ☐ Residence ☐ Place of Employment ☐ Other

Other (Incident Location) Conditionally Required if “Other” was selected above

* Is this a waiver funded location? Required

☐ Yes ☐ No

* Address of Incident Required

Additional Incident Details

* Were emergency services involved? Required

☐ Yes ☐ No

Please select the emergency services that were involved Conditionally Required if “Yes” was selected above

☐ Ambulance/Rescue/Paramedics ☐ Fire Department ☐ Crisis Team ☐ Warden Service – Search and Rescue

* Was Law Enforcement present? Required

☐ Yes ☐ No

Why was law enforcement present? Conditionally Required if “Yes” was selected above

☐ Charged with a Crime/Subject of an Investigation ☐ Victim of a Crime ☐ Planned Strategy/Unplanned Crisis Intervention ☐ Part of an Investigation ☐ None of the Above

* Did this incident result in an emergency room visit?

Required

☐ Yes ☐ No

* Is this/Do you suspect this incident is an allegation of abuse, neglect, or exploitation? Required

☐ Yes ☐ No

ALERT: As a Mandated Reporter per Title 22, Chapter 958-A; Adult Protective Services Act, you must call APS Intake at 1-800-624-8404 to report allegations of abuse, neglect, or exploitation.

* I understand that a 30-day provider follow up and internal review must be completed per 14-197 CMR Chapter 12 and will notify the responsible provider. Required ☐ Yes

* Who will complete the 30-day provider follow up and internal review per 14-197 CMR Chapter 12? Required

☐ Work Support Provider ☐ Community Support Provider ☐ Home Support Provider ☐ Agency Group Home Provider ☐ Shared Living Provider ☐ Case Manager

Reporter

* Reporter Type Required ☐ Contact

☐ Staff Member ☐ Person ☐ Self ☐ Other

Title

* First Name Required

* Last Name Required Relationship Role Select All that Apply ☐ Communication Ally

☐ Critical Information Monitor ☐ Interpreter ☐ Medical Monitor ☐ Power of Attorney ☐ Power of Attorney – Durable ☐ Surrogate ☐ Caregiver ☐ Emergency Contact ☐ Natural Support ☐ Next of Kin ☐ Private Conservator - Full ☐ Private Conservator - Limited ☐ Private Conservator - Emergency ☐ Private Guardian - Full ☐ Private Guardian - Limited ☐ Private Guardian - Emergency ☐ Private Representative Payee ☐ Supported Decision Making (SDM) Supporter

Email Phone Extension

* Reporter’s Involvement

☐ Witness ☐ Participant ☐ Hearsay

Witnesses/Participants

Please add more rows if necessary

Witness/Participant #1

* Relationship to Person Required

☐ Contact ☐ Staff Member ☐ Person ☐ Another Individual Receiving Services ☐ Reporter ☐ Self ☐ Other

* First Name Required

* Last Name Required Title Relationship Role Select All that Apply ☐ Communication Ally

☐ Critical Information Monitor ☐ Interpreter ☐ Medical Monitor ☐ Power of Attorney ☐ Power of Attorney – Durable ☐ Surrogate ☐ Caregiver ☐ Emergency Contact ☐ Natural Support ☐ Next of Kin ☐ Private Conservator - Full ☐ Private Conservator - Limited ☐ Private Conservator - Emergency ☐ Private Guardian - Full ☐ Private Guardian - Limited ☐ Private Guardian - Emergency ☐ Private Representative Payee ☐ Supported Decision Making (SDM) Supporter

* Individual’s Involvement

Witness/Participant #2

* Relationship to Person Required

☐ Contact ☐ Staff Member ☐ Person ☐ Another Individual Receiving Services ☐ Reporter ☐ Self ☐ Other

* First Name Required

* Last Name Required Title

Relationship Role Select All that Apply ☐ Communication Ally

☐ Critical Information Monitor ☐ Interpreter ☐ Medical Monitor ☐ Power of Attorney ☐ Power of Attorney – Durable ☐ Surrogate ☐ Caregiver ☐ Emergency Contact ☐ Natural Support ☐ Next of Kin ☐ Private Conservator - Full ☐ Private Conservator - Limited ☐ Private Conservator - Emergency ☐ Private Guardian - Full ☐ Private Guardian - Limited ☐ Private Guardian - Emergency ☐ Private Representative Payee ☐ Supported Decision Making (SDM) Supporter

* Individual’s Involvement

Notifications

* Was the person’s family notified? Required

☐ Yes ☐ No

* Was the guardian notified?

Required

☐ Yes ☐ No ☐ N/A

First Name Conditionally Required if “Yes” was selected above

Last Name Conditionally Required if “Yes” was

Why was the guardian not notified? Conditionally Required if “No” was

Incident Categories Please select all that apply

* Incident Category Required Please select all that apply

Incident Category Types Conditionally Required for Incident Categories Selected

☐ Death 14-197 CMR

CH12 2A i ☐ Suicide Attempt 14-

197 CMR CH12 2A ii Method of Suicide attempt: Please Select One ☐ Hanging ☐ Drowning ☐ Jumping ☐ Overdose ☐ Sharp object(s) ☐ Gun ☐ Other (please specify):

Did the suicide attempt result in a serious injury?

☐ Yes ☐ No Has the person attempted suicide previously?

☐ Yes ☐ No Was there any indication the suicide was planned?

☐ Yes ☐ No

☐ Suicide Threat 14-197 CMR CH12 2A iii

Type of threat: Please Select Any That Apply ☐ Expressed suicidal ideations ☐ Made a verbal or written threat to kill themselves ☐ Had a plan to carry out the suicide threat Has the person threatened suicide previously?

☐ Yes ☐ No

☐ Emergency Department Visit 14- 197 CMR CH12 2A iv

Was the individual transported to the emergency room by ambulance?

☐ Yes ☐ No ☐ Unknown

☐ Hospital Admission Planned/Unplanned

14-197 CMR CH12 2A

v

Was the hospital admission planned?

☐ Yes ☐ No

☐ Medication Error 14- 197 CMR CH12 2A vi

Please list medications involved:

Type of Error: Please Select One ☐ Refused to take prescribed medication ☐ Incorrect route ☐ Incorrect method of administration ☐ Incorrect dosage ☐ Incorrect schedule ☐ Took medication that was not prescribed ☐ Was not administered ☐ Did not follow procedures when assisting person with self-medication Reason medication error occurred: Please Select One ☐ Unfilled prescription ☐ Forgot ☐ Refusal ☐ Charting error

☐ Away from home with no medication available ☐ Other (please specify):

Who made the medication error? Please Select One ☐ Person ☐ Paid support ☐ Natural support Did the medication error result in any of the following? Please Select Any That Apply OR None of the Above ☐ Follow up with physician ☐ Emergency Department visit ☐ Death ☐ Life threatening situation ☐ Disability ☐ Hospitalization ☐ Required intervention ☐ None of the above

☐ Medical Treatment other than Hospital 14- 197 CMR CH12 2A vii

☐ Serious Injury 14-197 CMR CH12 2A viii

Type of Injury: Please Select Any That Apply ☐ Head trauma/concussion ☐ Laceration ☐ Broken/fracture bones ☐ Skin lesion/ulcer ☐ Burn ☐ Muscle/joint pain or dislocation ☐ Other injury (please specify):

Cause of Injury: Please Select One ☐ Accident ☐ Pre-existing condition ☐ Negligence ☐ Self-inflicted ☐ Unknown Where did the person receive treatment? Please Select Any That Apply ☐ Emergency room ☐ Hospital (admitted) ☐ Urgent care ☐ Physician’s office ☐ EMT/Paramedic ☐ Specialist Office

☐ Lost or Missing Person

14-197 CMR CH12 2A

ix

Did you observe the person leave?

☐ Yes ☐ No Did the person leave willingly?

☐ Yes ☐ No ☐ Unknown How long was the person missing? Please Select One ☐ Less than 1 hour

☐ 1-8 hours ☐ 8-24 hours ☐ More than 24 hours Did the person have a history of elopement? Please Select One ☐ Yes ☐ No ☐ Unknown

☐ Physical Plant Disaster

14-197 CMR CH12 2A

x

What was the cause for displacement? Please Select Any That Apply ☐ Building issues (Heating/Cooling/Plumbing/Electrical, etc.)

☐ Building code enforcement issues ☐ Natural disaster (Flood, Earthquake, Ice Storm, etc.)

☐ Pest infestation (Bugs, Rodents, etc.)

☐ Fire ☐ Other (please specify):

Select all the actions taken as a result of the displacement: Please Select Any That Apply ☐ EMT/Paramedic ☐ Fire ☐ Law Enforcement ☐ Crisis ☐ Other (please specify):

☐ Law Enforcement Intervention 14-197 CMR CH12 2A xi

Why was Law Enforcement involved? Please Select One ☐ Charged with a crime/subject of an investigation ☐ Victim of a crime ☐ Part of an investigation (witness, etc.)

☐ Planned strategy/unplanned crisis intervention

☐ Transportation Accident 14-197 CMR CH12 2A xii

What role did the person receiving services have in the transportation accident? Please Select One ☐ Pedestrian ☐ Cyclist ☐ Passenger in a motorized vehicle (car, ATV, boat, etc.)

☐ Operator of a motorized vehicle (car, ATV, boat, etc.)

☐ Physical Assault or Altercation 14-197 CMR CH12 2A xiii

Was the individual physically assaulted by another individual receiving services?

☐ Yes ☐ No Select the individual(s) the person initiated a physical altercation with:

Conditionally Required if “Yes” was selected above Please Select Any That Apply ☐ Staff ☐ Another individual receiving services ☐ Member of the community ☐ Friends/Family ☐ Other (please specify):

☐ Emergency Restraint

14-197 CMR CH12 2A

xiv

Type of restraint: Please Select One ☐ Personal holding ☐ Chemical restraint ☐ Blocking

Please indicate type of personal holding: Conditionally Required if “Personal holding” was selected above Please Select One ☐ Floor ☐ Sitting ☐ Standing Indicate 1 or 2 person: Conditionally Required if “Sitting” OR “Standing” was selected above Please Select One ☐ 1 Person ☐ 2 Person Restraint Method: Conditionally Required if “Personal holding” was selected above Please Select One ☐ Safety Care

☐ CPI

☐ TCI

☐ NAPPI

☐ MANDT

☐ Unknown Is this restraint outside of the approved plan? Please Select One ☐ Yes ☐ No ☐ N/A Single or Multiple restraint? Please Select One ☐ Single ☐ Multiple Restraint start and end times (If multiple, please list start/end times and duration for each restraint):

Total restraint time (in minutes):

Did this restraint result in an injury to the person? Please Select One ☐ Yes ☐ No ALERT: If this restraint resulted in a serious injury, please select the category “Serious Injury 14-197 CMR CH12 2A viii” ________Please describe: Conditionally Required if “Yes” was selected above

Did this restraint result in an injury to staff? Please Select One ☐ Yes ☐ No Please describe: Conditionally Required if “Yes” was selected above

☐ Rights Violation 14- 197 CMR CH12 2A xv

Type of rights violation: Please Select One ☐ Behavior modification ☐ Communications ☐ Discipline ☐ Discrimination ☐ Humane treatment ☐ Medical care ☐ Nutrition (i.e. food restriction) ☐ Personal property ☐ Physical exercise ☐ Religious practice ☐ Records (i.e. sharing of confidential information) ☐ Social activity ☐ Sterilization ☐ Voting ☐ Work

☐ Rights Violation:

Waiting for Approved Plan 14-197 CMR CH5 Section 5.07-2 B.10.

☐ Dangerous Situation

14-197 CMR CH12 2A

xvi ALERT: If this restraint resulted in a serious injury, please select the category “Serious Injury 14-197 CMR CH12 2A viii”

Who was at imminent risk of harm? Please Select One ☐ Person ☐ Other(s) ☐ Both Type of dangerous situation: Please Select One ☐ Arson ☐ Hostage taking ☐ Self-injurious behavior (cutting, head banging, biting, etc.)

☐ Other (please specify):