SELF REPORTED SELF REPORTED INCIDENTSINCIDENTS

How to Manage Them How to Manage Them Effectively Effectively

Leigh Grindley, RN, NHALeigh Grindley, RN, NHARegional Vice PresidentRegional Vice President

North RegionNorth RegionLaVie Management ServicesLaVie Management Services

ObjectivesObjectives

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

and monitoringand monitoring StatisticsStatistics SummarySummary

ELOPEMENTELOPEMENTHow do you decrease the How do you decrease the

likelihood of receiving an IJ for likelihood of receiving an IJ for an elopement in your facility?an elopement in your facility?

Elopement PreventionElopement Prevention• How do you assess your residents to How do you assess your residents to

determine if they are at risk for determine if they are at risk for elopement on admission and ongoing?elopement on admission and ongoing?

• What is your system and criteria for What is your system and criteria for identifying residents at risk?identifying residents at risk?

• How do you alert your staff that How do you alert your staff that residents are at risk?residents are at risk?

• What systems do you have in place to What systems do you have in place to keep your resident safe; wander keep your resident safe; wander guard system, increased supervision, guard system, increased supervision, door alarms etc?door alarms etc?

Elopement Prevention Elopement Prevention (cont.)(cont.)• How confident are you that the facility How confident are you that the facility

building structure is going to alert building structure is going to alert you if your residents attempt to leave you if your residents attempt to leave the facility?the facility?

• How confident are you that your staff How confident are you that your staff are monitoring the location of the are monitoring the location of the residents at risk?residents at risk?

• How confident are you that your staff How confident are you that your staff know your policy and procedure?know your policy and procedure?

• How are you monitoring compliance?How are you monitoring compliance?• Have you reviewed through your Have you reviewed through your

RM/QI Committee?RM/QI Committee?

Hot Liquid BurnsHot Liquid Burns

How do you decrease the How do you decrease the likelihood of receiving an IJ for likelihood of receiving an IJ for

a hot liquid burn?a hot liquid burn?

Hot Liquid Burn PreventionHot Liquid Burn Prevention How do you assess your residents How do you assess your residents

on admission and ongoing to on admission and ongoing to determine if they are at risk?determine if they are at risk?

In the event that you find that the In the event that you find that the resident is at risk, what systems resident is at risk, what systems have you implemented to keep have you implemented to keep your residents safe?your residents safe?

What adaptive equipment or What adaptive equipment or protective equipment are you protective equipment are you providing for the residents at providing for the residents at risk?risk?

How are you monitoring the How are you monitoring the safety of, and how are you safety of, and how are you supervising the resident?supervising the resident?

Hot Liquid Burn Prevention Hot Liquid Burn Prevention (cont.)(cont.)

What first aide equipment is in place What first aide equipment is in place in the event that the resident does in the event that the resident does spill hot liquid on their skin?spill hot liquid on their skin?

Do your staff know which residents are Do your staff know which residents are at risk and how to protect the resident at risk and how to protect the resident from a hot liquid burn?from a hot liquid burn?

Do your staff know how to provide first Do your staff know how to provide first aide if there is a burn?aide if there is a burn?

How are you monitoring compliance How are you monitoring compliance with your policy?with your policy?

Have you reviewed in your RM/QI Have you reviewed in your RM/QI Committee Meeting?Committee Meeting?

FULL CODE VERSUS DNRFULL CODE VERSUS DNR

What system do you have in place for What system do you have in place for assessment of your residents code assessment of your residents code status?status?

What system do you have in place for What system do you have in place for identifying the residents code status?identifying the residents code status?

Do you have an emergency cart Do you have an emergency cart available to your Nurses to utilize in available to your Nurses to utilize in the case of an emergency?the case of an emergency?

Do all staff know where it is located?Do all staff know where it is located?

FULL CODE VERSUS DNR FULL CODE VERSUS DNR (cont.)(cont.)

Is there an emergency cart checklist, Is there an emergency cart checklist, is the cart ready to use and is it being is the cart ready to use and is it being checked daily by the midnight shift?checked daily by the midnight shift?

Do your Nurses know how to perform Do your Nurses know how to perform CPR and have they been trained?CPR and have they been trained?

Does the Nurse understand his/her Does the Nurse understand his/her role when performing CPR on a role when performing CPR on a resident who is a full code?resident who is a full code?

How confident are you that your staff How confident are you that your staff can manage a code?can manage a code?

How are you monitoring compliance?How are you monitoring compliance? Have you reviewed through your Have you reviewed through your

RM/QI Committee?RM/QI Committee?

FallsFalls

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

Fall PreventionFall Prevention

What system do you have in place to What system do you have in place to determine if a resident is at risk for determine if a resident is at risk for falls on admission and ongoing?falls on admission and ongoing?

If a resident is at risk what If a resident is at risk what interventions are you implementing interventions are you implementing to decrease the likelihood of the to decrease the likelihood of the resident falling?resident falling?

How do you determine if the How do you determine if the interventions are in place?interventions are in place?

How do your staff know what the How do your staff know what the interventions are?interventions are?

Fall Prevention (cont.)Fall Prevention (cont.) Do you have a system for Do you have a system for

identifying residents at risk?identifying residents at risk? Does your staff know what the Does your staff know what the

system is and which residents system is and which residents are at risk?are at risk?

How do you know if your staff are How do you know if your staff are following the facility policy?following the facility policy?

How are you ensuring How are you ensuring compliance?compliance?

Have your reviewed in your Have your reviewed in your RM/QI Committee Meeting?RM/QI Committee Meeting?

What do I do if I have a Self What do I do if I have a Self Reported IncidentReported Incident

1.1. Ensure that the resident/residents are Ensure that the resident/residents are safe.safe.

2.2. As soon as practicable, complete a As soon as practicable, complete a thorough investigation to determine thorough investigation to determine what occurred. Interview the what occurred. Interview the resident, room mate, other residents, resident, room mate, other residents, staff who witnessed the event.staff who witnessed the event.

3.3. Assess the environment and Assess the environment and equipment.equipment.

4.4. Do not leave a stone unturned!!!Do not leave a stone unturned!!!

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

5.5. Review the policy and determine if Review the policy and determine if the policy was being followed?the policy was being followed?

6.6. Interview staff to determine if they Interview staff to determine if they followed the policy.followed the policy.

7.7. Review the chart in detail to Review the chart in detail to determine if the event was determine if the event was avoidable or unavoidable?avoidable or unavoidable?

8.8. Be critical of your process to Be critical of your process to determine the areas of risk?determine the areas of risk?

9.9. Identify the root cause of the eventIdentify the root cause of the event

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

10.10. Identify interventions to keep the event Identify interventions to keep the event from recurring and ensure they are from recurring and ensure they are implemented.implemented.

11.11. Take credit for the interventions Take credit for the interventions implemented in the chart; assessment, implemented in the chart; assessment, care plan etccare plan etc

12.12. Report to the State within 24 hours of the Report to the State within 24 hours of the event occurring. Send the 5 day report to event occurring. Send the 5 day report to the State within 5 working days.the State within 5 working days.

13.13. Review through your RM/QI Committee Review through your RM/QI Committee Meeting.Meeting.

How do I keep my other How do I keep my other residents safe residents safe

1.1. Identify the other residents at risk and Identify the other residents at risk and reassess them accordingly.reassess them accordingly.

2.2. Take credit for interventions implemented in Take credit for interventions implemented in the Residents charts; assessment and care the Residents charts; assessment and care plan.plan.

3.3. Provide training to relevant staff Provide training to relevant staff immediately. Do not let staff work until immediately. Do not let staff work until they have been trained.they have been trained.

4.4. Develop a Risk Management Quality Develop a Risk Management Quality Improvement Monitoring tool to ensure Improvement Monitoring tool to ensure compliance.compliance.

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

5.5. Initiate the implementation of the RM/QI Initiate the implementation of the RM/QI Tool immediately and review compliance Tool immediately and review compliance daily until you are satisfied that the daily until you are satisfied that the system is in compliance.system is in compliance.

6.6. Conduct an RM/QI Committee meeting to Conduct an RM/QI Committee meeting to review through your QA Process.review through your QA Process.

7.7. Review the system with your team and Review the system with your team and review if plan is not working.review if plan is not working.

8.8. Remember if the event is still occurring Remember if the event is still occurring then your plan needs to be reviewed.then your plan needs to be reviewed.

ROOT CAUSE ANALYSISROOT CAUSE ANALYSIS1.1. WHY, WHY, WHY, WHY,WHYWHY, WHY, WHY, WHY,WHY2.2. Interventions are band aids. If you Interventions are band aids. If you

don’t identify the root cause the don’t identify the root cause the event will occur again.event will occur again.

Example:Example:1.1. The microwave in the kitchen is The microwave in the kitchen is

dirty, why is it dirty?dirty, why is it dirty?2.2. Because the Kitchen Aide did not Because the Kitchen Aide did not

clean it.clean it.3.3. Why did the kitchen aide not clean Why did the kitchen aide not clean

it?it?4.4. Because she did not know that she Because she did not know that she

was supposed to clean it.was supposed to clean it.

ROOT CAUSE ANALYSISROOT CAUSE ANALYSIS5.5. Why did the kitchen aide not know that she Why did the kitchen aide not know that she

was supposed to clean it?was supposed to clean it?6.6. Because the Kitchen Supervisor had not Because the Kitchen Supervisor had not

trained her to do so.trained her to do so.7.7. Why had the Kitchen Supervisor not trained Why had the Kitchen Supervisor not trained

her to clean the microwave.her to clean the microwave.8.8. Because there were no cleaning schedules Because there were no cleaning schedules

in place to clean the microwave.in place to clean the microwave.9.9. What is the root cause of the microwave not What is the root cause of the microwave not

being cleanedbeing cleaned10.10. The kitchen aide had not been trained to The kitchen aide had not been trained to

clean the microwave and the Kitchen clean the microwave and the Kitchen Supervisor did not have a cleaning schedule Supervisor did not have a cleaning schedule in place, had not provided training to the in place, had not provided training to the kitchen aide and had not set expectations kitchen aide and had not set expectations to clean the microwave.to clean the microwave.

ROOT CAUSE ANALYSISROOT CAUSE ANALYSIS

1.1. Mrs. Brown has been found on the Mrs. Brown has been found on the floor five times in the past two floor five times in the past two weeks, what is the root cause?weeks, what is the root cause?

2.2. Mr. Jones fell forward out of his Mr. Jones fell forward out of his wheelchair at Bingo, what is the root wheelchair at Bingo, what is the root cause?cause?

3.3. Mr. Smith hit Mr. Jones in the Mr. Smith hit Mr. Jones in the hallway, what is the root cause?hallway, what is the root cause?

AVOIDABLE VERSUS UNAVOIDABLEAVOIDABLE 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: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

AVOIDABLE VERSUS UNAVOIDABLEAVOIDABLE VERSUS UNAVOIDABLE

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

AVOIDABLE VERSUS UNAVOIDABLEAVOIDABLE VERSUS UNAVOIDABLE

Example:Example: Resident ambulates independently Resident ambulates independently

and trips and falls. No previous and trips and falls. No previous evidence that would anticipate that evidence that would anticipate that this would happen.this would happen.

Resident goes out the door to the Resident goes out the door to the parking lot. No evidence that the parking lot. No evidence that the resident was at risk nor had resident was at risk nor had attempted this before this event.attempted this before this event.

Falls StatisticsFalls Statistics North Region North Region (10 facilities)(10 facilities)

2010 12010 1stst Quarter: 3.8% Quarter: 3.8% 2010 22010 2ndnd Quarter: 3.7% Quarter: 3.7% 2010 32010 3rdrd Quarter: Quarter: 3.6%3.6% 2010 42010 4thth Quarter: 3.5% Quarter: 3.5% 2011 12011 1stst Quarter: Quarter: 3.5%3.5% 2011 22011 2ndnd Quarter: Quarter: 3.4%3.4% Goal: < 4%Goal: < 4%

Complaint Survey Statistics Complaint Survey Statistics North Region North Region (10 facilities)(10 facilities)

2010 Complaint Surveys: 2010 Complaint Surveys: 1616 # surveys with no citations: # surveys with no citations: 9 9

(56.25%)(56.25%) 2011 Complaint Surveys: 2011 Complaint Surveys: 25 25 (up to June 2011)(up to June 2011)

# surveys with no citations: # surveys with no citations: 20 20 (80%)(80%)

Self Report Survey StatisticsSelf Report Survey StatisticsNorth RegionNorth Region(10 facilities)(10 facilities)

2010 SRI Surveys: 2010 SRI Surveys: 1616 # of surveys – no citation: 8 (50%)# of surveys – no citation: 8 (50%) 2011 SRI Surveys: 2011 SRI Surveys: 26 26 (ytd June 2011)(ytd June 2011)

# of surveys – no citation# of surveys – no citation 17 17 (65.38%) (65.38%)

SummarySummary Be proactive not reactive.Be proactive not reactive. Effective assessment on admission to identify risks.Effective assessment on admission to identify risks. Effective implementation of policy and procedures.Effective implementation of policy and procedures. Ongoing training of your staff.Ongoing training of your staff. Administrator and DON completing regular rounds Administrator and DON completing regular rounds

to oversee the implementation of policy and to oversee the implementation of policy and procedures.procedures.

Root cause analysis when an event does occur.Root cause analysis when an event does occur. Is the event avoidable or unavoidable?Is the event avoidable or unavoidable? Timely implementation of the 4 step process to Timely implementation of the 4 step process to

ensure resident and other residents are safe.ensure resident and other residents are safe. Utilization of your RM/QI Committee to review Utilization of your RM/QI Committee to review

successful 4 step process implementation.successful 4 step process implementation. Regular discussion with your Licensing Officer and Regular discussion with your Licensing Officer and

Survey Monitor.Survey Monitor.