Current through all regulations passed and filed through December 16, 2024
(A)
Purpose.
The purpose of this rule is to
establish standards and procedures to ensure that prompt and accurate
reporting; immediate evaluation; implementation of corrective and remedial
action; and preventative measures take place with the occurrence of each
incident. Effective incident reporting provides each hospital with individual
and cumulative incident report data to find problem areas and implement
corrective measures designed to prevent recurrence and manage risk. Analysis of
this data can reveal system issues and problems in need of corrective
action.
(B)
Applicability.
The provisions of this rule shall be
applicable to all hospital inpatient and community support network (CSN)
programs under the managing responsibility of the department. Subject to this
rule, all occurrences during an inpatient stay or within thirty days of
discharge must be recorded in the patient care system regardless of other
reporting requirements (i.e., the joint commission, department of health,
etc.).
(C)
Definitions.
The following definitions shall apply
to this rule in addition to those appearing in rule
5122-1-01 of the Administrative
Code:
(1)
"Absent without leave" or "AWOL" means a patient has
breached the secure perimeter of the hospital without permission, has eloped
during, or has not returned from an authorized absence from the facility. The
reporting of AWOLs is determined in paragraph (D)(6) of this
rule.
(2)
"Abuse" means any act or absence of action caused by
an employee inconsistent with rights which results, or could result in physical
injury to a patient; any act which constitutes sexual activity, as defined
under Chapter 2907. of the Revised Code, where such activity would constitute
an offense against a client under that chapter; insulting or coarse language or
gestures directed toward a client which subjects the client to humiliation or
degradation; or depriving a patient of real or personal property by fraudulent
or illegal means.
(a)
There are five sub-types of abuse: physical, verbal,
sexual, neglect, and defraud. If there are multiple sub-types to an incident,
only select the most severe sub-type when recording an incident. For example,
if a patient alleges both physical and verbal abuse, code the allegation as
"physical." All incidents of abuse are "major."
(b)
When recording
"alleged abuse," the staff person alleged to have committed abuse shall be
coded as "perpetrator" and the patient as "victim."
(c)
Frequent
allegations of sexual abuse shall be investigated, but need not be reported as
incidents unless such allegations are founded. However, record of the
allegations and subsequent investigations shall be recorded in the clinical
record and addressed in the treatment plan.
(3)
"Accident" means
any incident that results from an unintentional occurrence.
(a)
There may or may
not be injuries associated with an accident. When an injury or injuries occur,
the following codes shall be utilized to classify the accident:
(i)
Patient or staff
injury resulting from a restraint which requires more than first-aid is a
"major" incident.
(ii)
Patient or staff injury needing no treatment or
first-aid is a "minor" incident.
(iii)
Patient or
staff injuries needing medical treatment may be "minor" or "major," depending
on the severity.
(b)
Unexpected
hospitalization (including observation) resulting from an accident is a "major"
incident.
(c)
All "accident/falls" and "accident/choking on food"
with or without injuries shall be considered as reportable incidents as defined
in paragraph (C)(20) of this rule.
(d)
When recording
an "accident," staff shall indicate whether the accident was observed or not
observed by staff.
(4)
"Assault" means
to knowingly or recklessly cause or attempt to cause physical harm to another.
Assault is distinct from a threat, in that assault is an actual attempt to
cause physical harm instead of a statement alluding to such action. An
allegation of an employee assaulting a patient shall be reported as "alleged
abuse." Assault includes all types of physical aggression except when further
defined under "abuse."
Assault has four sub-types: sexual,
physical, weapon, and other.
(a)
All physical assaults resulting in the need for
admission to a general hospital shall be classified as "major" incidents.
Physical assaults requiring more than first-aid and less than admission to a
general hospital shall be classified as "major" or "minor" at the discretion of
the CEO. Physical assaults requiring less than first-aid shall be classified as
"minor" incidents.
(b)
All weapon assaults shall be classified as "major"
incidents.
(c)
An allegation of sexual assault that involves
non-consensual sexual conduct shall be further classified as rape. A rape
allegation shall be reported as a "major" incident.
(d)
Frequent
allegations of sexual assault resulting from fixed delusions shall be
investigated, but need not be reported as incidents unless the allegations are
founded. However, record of such allegations and subsequent investigation shall
be recorded in the clinical record and addressed in the treatment
plan.
(e)
When two persons are fighting and it is unclear or
unknown who started the fight, both persons shall be coded as "perpetrators."
Otherwise, individuals involved shall be coded either "perpetrator" or "victim"
as appropriate. Of the persons involved, the one with the highest level of
injury determines the incident status ("major" or "minor") for the whole
incident.
(5)
"Attempted suicide" means an unsuccessful attempt to
end one's own life with a finding of intent as determined by a clinician.
(a)
Attempted
suicide is a "major" incident.
(b)
Suicidal
thoughts should not be reported as incidents but should be documented in the
patient's chart.
(c)
When recording attempted suicide, the patient should
be coded as "victim."
(6)
"Chief clinical
officer" or "CCO" means the medical director of an RPH as defined in division
(K) of section 5122.01 of the Revised
Code.
(7)
"Chief executive officer" or "CEO" means an individual
who directs and oversees the operation of an RPH.
(8)
"Confirmed
abuse/neglect" means an allegation of abuse or neglect has been proven to have
occurred.
(9)
"Contaminated/unknown sharps injury" (i.e., needle
sticks, etc.) means the injury of any person involved. Those at greater than
first-aid may be considered a "major" incident depending upon severity, and all
others are "minor" incidents.
(10)
"Contraband and
restricted/controlled items" means those items that are not permitted on state
property pursuant to law or hospital policy. The following shall be considered
contraband:
(a)
All weapons or potential weapons including, but not limited
to, guns, knives, electronic control devises such as tasers and stun guns,
defensive aerosol sprays, ammunition and explosives;
(i)
If weapons or
potential weapons are brought onto or found on state property, the incident
shall be reported as "major." Firearms or electronic control devices in the
possession of peace officers shall not be reported unless such items are
brought onto patient units;
(ii)
Discharge of a
weapon or electronic control device on RPH property is considered a "major"
incident;
(iii)
Intoxicating beverages and illicit drugs including,
but not limited to, non-prescribed prescription drugs and illegal drugs;
and
(b)
If police arrest
an individual for possession of contraband or restricted/controlled items, the
incident shall be considered "major." Possession of other contraband and
restricted/controlled items shall be considered "minor" incidents unless stated
otherwise in this rule.
(11)
"Critical major
incident" means an event for which there is a need to immediately advise the
deputy director of hospital services, the ODMH medical director and the ODMH
director of the situation. These include, but are not limited to, death; rape;
injury which may result in permanent loss of functioning; AWOL of a forensic
patient; AWOL of a patient whose life may be endangered because of weather,
illness, poor judgment, or other conditions; power failure which is not quickly
resolved; loss or exposure of personal health information (PHI); fire (at the
discretion of the CEO); and all sentinel events as defined in rule
5122-2-25 of the Administrative
Code.
(12)
"Death" means the death of a patient while on hospital
rolls or within thirty days of discharge.
(a)
If type of death
is unknown, select "pending."
(b)
The person who
dies should always be coded as the "victim."
(c)
Death is a
"major" incident if the person died while an inpatient, or within thirty days
of discharge. If death was a result of suicide or other non-natural causes
while an inpatient, or within thirty days of discharge, it is a "critical
major" incident.
(13)
"Equipment or
utility failure or malfunction" means any unplanned malfunction or failure of
essential utility systems including, but not limited to: electrical power
distribution; plumbing (water and waste disposal); natural gas; emergency power
(generators); elevators; air-conditioning (HVAC); boilers; and communications
or patient care/medical equipment (including ADMs) that do not function
according to their designed purpose and could result in a potentially unsafe
situation for patients, staff and visitors.
(a)
Equipment or
utility failure which requires a repair in excess of one thousand dollars;
having a significant impact on the operation of the RPH (as determined by the
CEO or designee); or requiring the evacuation of a building shall be coded as a
"major" incident.
(b)
Other instances shall be considered "minor"
incidents.
(14)
"Fire" means the burning of a solid, liquid, or gas
that must be extinguished to prevent the spread of the fire or smoke from
endangering patients, staff, visitors, or buildings.
(a)
Any fire that
results in an injury, a fire department response to extinguish, or an
evacuation of a building is a "major" incident.
(b)
Other types of
fires shall be considered as "minor" incidents.
(15)
"Illicit use or
possession of drugs or alcohol" means that a person is suspected of or actually
under the influence of alcohol or drugs.
(a)
If the person is
arrested, the incident is "major."
(b)
All other
incidents shall be considered "minor."
(16)
"Illness or
medical emergency" means physical illnesses such as infections, kidney
problems, cardiac emergencies, etc., which require treatment outside the
RPH.
(a)
Unexpected hospitalization (including observation) due to illness or medical
emergency is a "major" incident. However, if a person is examined and treated
and sent back to the RPH without being admitted, the incident shall be
considered "minor."
(b)
Scheduled trips or admissions to other medical
facilities for planned medical or surgical interventions are not reported as
illnesses or medical emergencies.
(17)
"Inappropriate
sexual behavior" means public masturbation, sexual touching, inappropriate
kissing, making repeated or targeted inappropriate sexual comments, sexual
advances, and attempts to have or to have had sexual intercourse by any person.
Non-consensual sexual intercourse is classified as "rape."
(a)
If a staff
person is involved as the perpetrator against staff, visitors, or others, the
incident is "major."
(b)
Staff-to-patient inappropriate sexual behavior is
considered "patient abuse."
(c)
If a patient,
visitor, or other is involved as the perpetrator, the incident may be
considered "major" at the discretion of the CEO/designee.
(18)
"Incident" means any occurrence which is not consistent with the routine care
of a patient, the routine services provided by the hospital, or the routine
standard of care for the hospital. Incidents may involve patients, employees,
visitors, and other persons as further specified in this rule. Incidents
involving patients are not restricted to those occurrences on the hospital's
premises. Also included is any patient who is on the rolls of the hospital and
is involved in an incident while away from the hospital.
(19)
"Injury to
staff while restraining a patient" means injury to any employee while in the
process of restraining a patient, or while the patient is in seclusion and
restraint. This category includes any injuries sustained in an accident that
occurred as a direct result of responding to a restraint event.
(a)
All injuries
requiring more than first-aid as a result of restraint are
"major."
(b)
Injuries needing no treatment or first-aid are
"minor."
(20)
"Major incident" means an occurrence severe enough to
warrant special categorization for purposes of reporting and includes the
following:
(a)
Injury or illness which results in admission to a general
hospital;
(c)
AWOL as further
defined in paragraph (D)(6) of this rule;
(d)
Property damage,
loss, or theft valued at more than one thousand five hundred
dollars;
(e)
Injury occurring during the course of restraint that
requires more than first-aid;
(f)
Medication
errors of level five or six;
(h)
Assault resulting in admission to a general hospital;
or rape; or weapon assault;
(j)
Weapons or potential weapons brought onto or found on
state property;
(k)
Discharge of a weapon or electronic control device on
RPH property;
(l)
Arrest of an individual for possession of contraband
or restricted/controlled items;
(m)
Inappropriate
sexual behavior by a staff person against staff, visitors, or others; or
neglect of patients;
(n)
Threats toward specific public officials; bomb threats
that require the evacuation of a building; or threats sufficient to warrant a
warning as found in section
2305.51 of the Revised Code, and
rule 5122-3-12 of the Administrative
Code ("Duty to protect");
(o)
Missing medication which requires a police
investigation;
(p)
Any incident requiring an outside police
investigation;
(q)
Unauthorized use of restraint;
(r)
Any fire
resulting in an injury, a fire department response to extinguish, or an
evacuation of a building;
(s)
Illicit use of alcohol or drugs resulting in an
arrest;
(t)
Anything judged by the CEO as being a "major"
incident;
(u)
Equipment or utility failure which requires a repair
in excess of one thousand dollars; has a significant impact on the operation of
the RPH (as determined by the CEO or designee); or requires the evacuation of a
building; or
(v)
Any violation where an outside agency is notified, or
for a potential violation of existing workplace violence policy(ies) of the
department.
(21)
"Medication error" (also called "medication variance")
means any preventable event that may cause or lead to inappropriate medication
use or patient harm while the medication is in the control of the health care
professional, patient, or consumer. Such events may be related to: professional
practice; health care products; procedures and systems, including all aspects
of prescribing (i.e., order communication, product labeling, packaging,
nomenclature, compounding and dispensing, distribution, administration,
education, monitoring and use). Medication errors are assigned a severity level
based on ODMH policy MD-03, "Medication Errors."
(a)
All medical
errors of level five or six are "major" incidents.
(b)
Medication
errors of level zero through four are not considered incidents but should be
documented pursuant to ODMH policy MD-03, "Medication Errors."
(22)
"Minor incident" means those types of occurrences which do not appear to be
severe or detrimental to the best interests of the patient, department, RPH or
personnel.
(23)
"Missing medication" means an incident where
medication is unaccounted for, such as when a patient returns from authorized
leave without the medication with which they were provided; or when controlled
medications are missing from the ADM machines after the count has been
reconciled.
(a)
All incidents requiring police investigation are "major."
(b)
All other
incidents are "minor."
(24)
"Neglect" is
defined in rule
5122-3-14 of the Administrative
Code as "a purposeful or negligent disregard of duty imposed on an employee by
statute, rule, RPH policy, position description, or professional standard and
owed to a client by that employee." Responses to allegation of abuse or neglect
shall be consistent with the requirements of rule
5122-3-14 of the Administrative
Code.
(25)
"Office of quality assurance and improvement" means
the office of quality assurance and improvement of ODMH.
(26)
"Other" means
the classification of an incident when no other incident type appropriately
describes an incident.
(27)
"Patient care system" or "PCS" means the official
secure centralized ODMH automated database where patient demographic and
related information is maintained.
(28)
"Policy
violation (staff only)" means any act where staff has perpetrated an incident
and no other incident type appropriately describes the incident. When recording
this type of incident, one must record the policy violated as well.
(a)
Any violations
where an outside agency is notified or the workplace violence policy
potentially has been violated are "major."
(b)
All other
incidents may be "major" or "minor" incidents depending upon the severity of
the incident as determined by the CEO or designee.
(29)
"Program" means
any service provided by ODMH employees.
(30)
"Property
damage" means accidental damage to property, but may also include damage due to
negligence or intentional acts by entities outside the hospital. For example, a
falling tree that hits a car; damage due to patient behavior; and vandalism
constitute property damage.
(a)
Property damage greater than one thousand five hundred
dollars or that has a significant impact on the operation of the organization
(as determined by the CEO or designee), or that requires the evacuation of a
building are "major" incidents.
(b)
All other
property damage incidents are "minor."
(31)
"Property loss"
means accidental or negligent loss of department or state of Ohio property. If
the value of the property is greater than one thousand five hundred dollars, or
involves a loss of protected health information, the incident is "major." All
other property loss incidents are "minor."
(32)
"Self-injurious
behavior" means an act of self-induced bodily harm that is not intended to kill
oneself.
(a)
Injury of any person involved at greater than first-aid should be considered
"major."
(b)
Injuries needing only first-aid are "minor"
incidents.
(33)
"Sentinel event" means an event defined in rule
5122-2-25 of the Administrative
Code.
(34)
"Theft" means the taking of another person's property
without the person's permission or consent. Allegations of theft of patient
property by employees should be reported as "major" under "alleged patient
abuse."
(a)
Any theft of property which constitutes a substantial value as determined by
the CEO or designee, in consultation with the department's security consultant,
is a "major" incident.
(b)
The theft of property which is not considered of
substantial value is a "minor" incident.
(35)
"Threat" means
behavior meant to intimidate a person such that there is a reasonable fear of
bodily harm through the use of threatening words and/or conduct without use of
a weapon or actual physical attack. Threats include, but are not limited to,
bomb threats, threats of aggression or violence, threats against public
officials, spousal threats thought to be serious, stalking, and menacing.
(a)
Threats towards
specific public officials, bomb threats that require the evacuation of a
building, or threats sufficient to warrant a warning as found in section
2305.51 of the Revised Code and
rule 5122-3-12 of the Administrative
Code ("Duty to Protect") are "major" incidents.
(b)
Others are
"minor" incidents.
(36)
"Unauthorized
movement" or "UM" means any incident where the patient has been absent from a
location, within the facility defined by the patient's privilege status
regardless of the patient's leave or legal status. A patient should be
considered UM if the patient has not been accounted for when expected to be
present. Implicit in this definition is the notion that the patient has been
informed of the limits placed on her/his location or movement prior to the UM
incident. All UM incidents are considered "minor."
(37)
"Unauthorized
use of restraint" means instances where hospital policies and procedures were
not followed in authorizing the use of seclusion or restraint. All instances
are considered "major" incidents.
(38)
"Unfounded
abuse/neglect" means that an allegation of abuse or neglect was not supported
by evidence upon investigation.
(39)
"Unproven
abuse/neglect" means it could not be proven that the incident did or did not
happen. There may have been conflicting or inadequate evidence to either prove
or disprove that the abuse/neglect occurred.
(D)
Reporting of
incidents.
(1)
All incidents shall be documented and reported in accordance with the
provisions of this rule and on the forms and database prescribed by the
department.
(2)
Investigation of incidents.
(a)
The CEO shall
develop an investigative procedure to be followed by employees in response to
the occurrence of all incidents.
(b)
Based on the
severity of the occurrence, some incidents shall be reported to central office
as defined in paragraphs (D)(4) to (D)(7) of this rule.
(3)
Incidents classified as "major";
(a)
Major incidents shall include, but not be limited to
the following:
(ii)
All deaths. In
addition, the following deaths shall be reported immediately to the coroner and
the Ohio state highway patrol:
(a) Suicide;
(b) Accidental death regardless of cause;
(c) Apparent or possible homicide; and
(d)
Any suspicious or unusual death.
(iii)
Events
determined by the CEO or designee and/or CCO or designee that require the
immediate investigation by the local law enforcement agency and/or the Ohio
state highway patrol. Examples include:
(a) Serious injury caused by another person, whether another
patient, employee, or any other person;
(b) Alleged criminal act of an employee committed on hospital
grounds or while performing occupational duties off-grounds which may result in
a felony or misdemeanor charge;
(c) Alleged criminal act of a patient which may result in a
felony or misdemeanor charge; and
(d)
Alleged criminal act on RPH grounds by person other than an
employee or patient which may result in a felony or misdemeanor
charge.
(iv)
Severe weather conditions resulting in the disruption
of the normal operation, safety, and/or security of the RPH;
and
(v)
All "major" incident types as further defined in
paragraph (C)(20) of this rule.
(4)
General
reporting requirements.
(a)
The employee who discovers or witnesses an incident,
or to whom an incident is reported, is responsible for documenting the
incident, cooperating in the investigation, and providing the investigating
officer or staff with a complete statement or statements as
needed.
(b)
The incident notification report (DMH-ADM-005a or
DMH-CSN-008, as appropriate) required by ODMH shall be completed for each
incident. Each CSN also has additional reporting responsibilities utilizing
form DMH-0484/LIC-015.
(c)
Facts regarding the incident shall be reported in
writing. No unsubstantiated conclusions, opinions, hearsay, assumptions, or
accusations shall be included in the incident report.
(d)
The incident
report shall not be filed, nor references to an incident report made, in the
patient medical record. However, those events which have a direct medical or
clinical effect on the patient should be recorded in the patient medical
record. The incident report shall be maintained in an administrative file. The
CEO shall utilize a procedure for the filing and internal management of
incident reports.
(e)
Incident reports shall be maintained in a confidential
manner and be accessible only to authorized employees except by consent of the
CEO in consultation with the department's legal office.
(i)
The Ohio state
highway patrol may have access only to the incident notification report form
(DMH-ADM-005a) or the CSN incident notification report form (DMH-CSN-008) upon
request.
(ii)
If requested, the local mental health board only shall
have access to information on the incident notification report form
(DMH-ADM-005a) or the CSN incident notification report form
(DMH-CSN-008).
(f)
The CEO shall designate a person to be responsible for
notifying the parents, spouse, legal guardian, or legal custodian of a patient
about the occurrence of an incident involving a patient. This disclosure shall
require the consent of the patient except if the patient is deceased, AWOL, or
unconscious.
(g)
The CEO shall develop a policy that determines which
hospital staff are to be notified of the occurrence of
incidents.
(5)
Immediate reporting to central office.
(a)
Utilizing the
telephone call-in procedure defined in ODMH policy I-05, ("Central Office
Administrative Officer of the Day"), the CEO or designee shall report at all
times, the occurrence of any of the following major incidents to the deputy
director of hospital services.
(ii)
AWOL of a
patient as defined in paragraph (D)(6) of this rule;
(iii)
Fires, as
defined in paragraph (C)(14) of this rule;
(iv)
Equipment or
utility failure or malfunction as previously defined in paragraph (C)(13) of
this rule that may result in significant potential danger, as determined by the
CEO or designee, to staff and/or patients (i.e., loss of fire alarm or
suppression systems, telephone service, emergency generator, or water/sanitary
systems);
(v)
Other incidents, as determined by the CEO or designee,
that are critical in nature and may result in significant danger to staff
and/or patients (i.e., a hostage situation, a flood, severe weather conditions,
bizarre or unusual crimes or events); and
(vi)
Any incident,
as determined by the CEO or designee, that would likely result in news media
coverage.
(b)
All incidents that involve a morbidity, mortality, or
reviewable sentinel event, as defined in rule
5122-2-25 of the Administrative
Code, "Morbidity, mortality, and sentinel event," shall be reported to the ODMH
medical director or designee by the hospital CCO or designee via telephone or
email.
(c)
For incidents listed in paragraphs (D)(5)(a) and
(D)(5)(b) of this rule which occur between five p.m. and eight a.m. Monday
through Friday and all day on weekends and holidays, the CEO or designee shall
contact the ODMH administrator on duty pursuant to ODMH policy I-05, ("Central
Office Administrative Officer of the Day").
(6)
AWOL reporting
procedure.
(a)
AWOLs are reportable to central office as either "minor," "major," or "critical
major" incidents. All AWOL data shall be tracked internally by RPH procedures
and monitored through quality improvement activities. Incident reports
involving AWOLs shall include the time and date the patient eloped, when the
patient was returned (or discharged), location where found, and a description
of all activity that may have occurred while the patient was
AWOL.
(b)
AWOL as a "critical major" incident.
The following AWOLs are considered
reportable as "critical major" incidents.
(i)
AWOL of patients
considered at risk to self or others for which, because of their psychiatric
history, criminal history, legal status, immigration status, or current
psychiatric condition or behavior, there is a need to notify state or federal
law enforcement (i.e., Ohio highway patrol, federal marshal's office, FBI,
secret service, or homeland security, respectively); or
(ii)
Any AWOL not
identified in paragraph (D)(6)(b)(i) of this rule that the hospital's CEO,
designated AoD or deputy director deems to be reported as such (i.e., imminent
threat to self or others, extreme adverse weather conditions, fragile medical
status, etc.);
(iii)
The RPH CEO or designee shall report an AWOL that is
considered to be a critical major incident to the ODMH hospital services deputy
director immediately upon discovery. The deputy director may be reached by
calling the twin valley behavioral healthcare Columbus switchboard at
614-752-0333. Alternatively, the reporting CEO or designee may contact the
deputy director through the cell phone.
(c)
AWOL as "major"
incident.
When a patient falls under a certain
legal status, or meets specific criteria, the incident is reportable as a
"major" incident to central office. These incidents fall within the following
categories:
(i)
Forensic AWOL: all patients with a forensic legal
status or tracked as forensic and listed in the following divisions and
sections of the Revised Code:
(a)
2945.371(G)(3)
- competency evaluation;
(b)
2945.371(G)(4)
- sanity evaluation;
(c)
2945.38(B) -
IST-R;
(d)
2945.38(H)(4)
- IST-U;
(e)
2945.39(A)(2)
- IST-U-CJ;
(f)
2945.401 -
IST-U-CJ-CR;
(g)
2945.40 - NGRI ;
(h)
2945.402(A) -
NGRI-CR;
(i)
2967.22 -
parole/probation;
(j) Police hold/capias; or
(k) Jail transfer.
(ii)
Risk of harm to
self or others: All patients who, in the judgment of the CCO, are the
following:
(a) At risk of harming self or others;
(b) Currently held on an emergency certificate under section
5122.10 of the Revised
Code;
(c) Adjudicated at risk by a probate court under division (B)
of section 5122.01 or division (C) of
section 5122.15 of the Revised
Code.
(iii)
The RPH CEO or designee shall report an AWOL that is
considered to be a major incident to the ODMH hospital services deputy director
immediately upon discovery. The deputy director may be reached by calling the
twin valley behavioral healthcare, Columbus switchboard at 614-752-0333.
Alternatively, the reporting CEO or designee may contact the deputy director
anytime through the cell phone.
(d)
AWOL as a
"minor" incident.
An AWOL that does not fall under the
classifications described in paragraphs (D)(6)(b) and (D)(6)(c) of this rule
shall be considered a "minor" incident, (i.e., a voluntary patient who is not
considered at risk to self or others). RPHs shall be responsible for
maintaining information about AWOLs classified as "minor" incidents but no
telephone reporting to central office is required.
(e)
Notice of
discharge requirements for forensic patients.
In accordance with division (A) of
section 5122.26 of the Revised Code, the
RPH CCO may discharge a patient who is under indictment, sentence of
imprisonment, or on probation or parole and who has been AWOL for more than
thirty days, but shall give written notice of the discharge to the court having
criminal jurisdiction over the patient.
(i)
Within ODMH
RPHs, this statute is applicable to patients in the following forensic
categories: NGRI, IST-U, IST-R, IST-U-CJ, parolee/probationer, jail transfer,
capias, and patients on conditional release status.
(ii)
The RPH shall
also notify the ODMH division of legal and regulatory services and the ODMH
office of forensic services of the planned discharge of all patients indicated
in this section.
(f)
Discharge of
civil patients.
The CCO of a RPH may discharge any
other (civil) patient who has been AWOL for more than fourteen
days.
(g)
External AWOL reporting requirements.
The RPH CEO is responsible for
additional notification to external agencies in certain cases. For external
reporting purposes, the CEO is responsible for developing policies for the
timely notification of "critical major" and "major" AWOL incidents to the
following agencies:
(i)
Ohio state highway patrol and local law enforcement
regarding information about individuals that the patient has threatened and RPH
think could be in danger;
(ii)
County
prosecutor and local law enforcement agencies (forensic patients) in accordance
with ODMH policy I-12, "Apprehension of Forensic Patients who Leave RPH
Grounds";
(iii)
Victim or victim representatives in accordance with
section 2930.16 of the Revised
Code;
(iv)
The respective community mental health board;
and
(v)
Federal authorities (i.e., secret service, the federal
marshal's office, etc.) as appropriate.
(h)
Quality
assurance and quality improvement.
The ODMH division of hospital services
will monitor RPH AWOL information (incident reports) and data collection and
provide aggregate reports, including analysis of trends, on a quarterly
basis.
(7)
Other procedures for reporting to central
office.
(a)
All
incidents involving a morbidity, mortality, or sentinel event shall be reviewed
and reported to the hospital services morbidity and mortality committee as
specified by rule
5122-2-25 of the Administrative
Code, "Morbidity, mortality, and sentinel event."
(b)
All major
incidents as defined in paragraphs (D)(3) and (D)(6) of this rule shall be
reported within twenty-four hours of the incident to the division of hospital
services using the "Incident Notification Report" form (DMH-ADM-005a); and the
"Major Incident Report" form (DMH-7034), with copies going to the following as
indicated on DMH-7034.
(i)
Deputy director of hospital services;
(ii)
ODMH medical
director;
(iii)
Deputy director of legal and regulatory
services;
(iv)
Chief of the office of legal services;
(v)
Staff counsel in
the office of legal services;
(vi)
ODMH security
consultant;
(vii)
Assistant deputy director of hospital services;
and
(viii)
Clinical safety director of hospital
services.
(c)
For inpatient programs, all major incidents, including
those mentioned in paragraph (D)(6) of this rule, shall be reported to the ODMH
office of quality assurance and improvement in central office within
twenty-four hours of the incident using the automated PCS incident notification
report system, and forms DMH-ADM-005a and DMH-7034.
(d)
For CSN
programs, all major incidents must be reported to the ODMH office of quality
assurance and improvement in central office within twenty-four hours of
learning of the incident, using the "CSN Incident Notification Report" form
(DMH-CSN-008) and DMH-7034. In addition, the CSN, including its licensed
residential facilities, shall report outpatient services incidents in
accordance with rule
5122-26-13 of the Administrative
Code using "Community Mental Health Agency Notification of Incident" form
(DMH-LIC-015c); and report residential facility incidents in accordance with
rule 5122-30-16 of the Administrative
Code using "Residential Facility Notification of Incident" form
(DMH-LIC-015r).
(e)
The ODMH office of quality assurance and improvement
may require such other reports or documents as are necessary to conclude a
review of any incident. Data regarding all incidents shall be maintained in a
form specified by central office.
(f)
Data regarding
minor incidents shall be maintained in a form specified by central office using
the automated PCS incident notification report system.
(E)
Individual and aggregate analysis.
(1)
Each hospital
and CSN program shall ensure that all incidents are thoroughly and
comprehensively reviewed and analyzed:
(a)
At the time of
submission, on an individual basis, for adequacy of documentation and necessity
for follow-up; and
(b)
At regular intervals and yearly, on an aggregate
basis, to determine rends or patters indicative of a need for corrective
action. Such information shall be made available to the ODMH office of quality
assurance and improvement.
(2)
At regular
intervals, the ODMH office of quality assurance and improvement shall supply
RPHs with aggregate data on incidents.
(F)
Implementation
of incident reporting.
The CEO of each RPH shall be
responsible for prescribing guidelines for implementation of this
rule.
Replaces: 5122-3-13
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