1. ADPH Report
ALAA Fall Conference
2019

2. 4/1/19-8/31/19
ALF
SCALF
Totals
Surveys 49 26 75
Enforcement 1 2

3. Investigating and REPORTING INCIDENTS

6. WHY ARE YOU REQUIRED TO INVESTIGATE?
Investigations are required to determine the cause of an undesired outcome.
If you don’t know how something occurred, how can you successfully prevent it from happening again?

7. Investigation may be likened to the long months of pregnancy, and solving a problem to the day of birth. To investigate a problem is, indeed, to solve it.     

8. Incident Investigation
(3)(h)
(3)(h)
When an incident occurs in an assisted living facility;
The facility administrator shall be immediately notified.
The facility shall conduct a thorough investigation.
Appropriate corrective actions and interventions shall be devised and implemented immediately.
A detailed and accurate report shall be completed within 72 hours of the incident.
The report shall be given immediately upon completion to the administrator for review.

9. Thorough executed without negligence or omissions
extremely attentive to accuracy and detail
complete; perfect; utter
Someone who is thorough does everything that they should and leaves nothing out.

10. A Thorough Investigation
In addition to items required by facility policies and procedures, the items that shall be included in an investigation are listed in the rules. There is no guess work, you can’t go wrong if you use the rule book!
A thorough investigation should answer the following questions
Who
What
When
Where
How

11. Implement Appropriate Corrective Actions and Interventions Immediately

12. The investigative file includes the incident report itself, the incident investigation and all records, documents, statements, images, and information created or reviewed in connection with the investigation.
The entire investigative file shall be made available for inspection and copying by representatives of the Department upon request.
The entire investigative file and documentation of all corrective action taken shall be retained for a period of not less than 3 years after the resident is discharged or dies.
Interventions devised as a result of the investigation shall be included in a resident record that is available to the personal care staff.

13. Reporting Incidents

14. Incidents that are reportable, as listed in the rules, shall be reported to the Department’s Online Incident Reporting System within 24 hours of the incident.

15. Any medication error, overdose, or over sedation
“Medication Error” means any preventable event that causes or leads to inappropriate medication use or harm while medication is in the control of the assisted living facility staff or resident.”
Since April 6, 2019 there have been 150 medication errors reported.
Approximately 85 % of those errors were committed by licensed nurses.
Common Errors- Transcription errors, ALF residents taking wrong medications, physician orders, medications and MARs do not match, medications are documented as given but are found on the cart, missed medications due to unavailability and late medications.

16. Things to Remember When Reporting to the Online Reporting System
Your description of the incident should be brief and concise.
Do not use abbreviations or acronyms that are not common to everyone.
Include names of all staff on duty at the time of the incident.
Do not include documentation that was not requested by the Department.
Proof read your report before you submit it.

17. Taken from actual incident reports
Resident fell getting out of bed to go to the restroom. Unwitnessed fall
Resident lost footing in bathroom and had not used handrails to stable themselves
Caregiver reported resident took Synthroid that was not his medication
Medication packets labeled 7/8/19 PM were found on cart on 7/9/19. Packets were unopened. Medications were charted as given.
Resident to receive Lorazepam 1mg twice daily. Nurse accidentally administered 2 pills at 8AM.
Associate during routine med pass gave resident 19 units of Lantus instead of 19 units of Humalog.
Care associates Oh My and Good Grief had a physical altercation that was witnessed by Mrs. Scared To Death. The altercation was not intended to hurt the resident.
Resident found on floor in the bathroom in the shower right side with rollator on top of her. It appears the resident lost her balance when trying to exit the bathroom. –Multiple fractures of ribs on left side.

18. Resident reported that as she was coming out of her bathroom she lost her balance, and her swung her hand out to catch herself and hit her left hand on the bathroom counter. Reported as “any intentional self-inflicted injury”
Resident found lying on the supine in the floor. This is the 3rd fall in a less than 24 hours.
She fell out of wheelchair on her way to the table. Intervention- Make sure her brace is on her leg to help keep it stable and not bouncing.
Resident fell in her apartment on Resident made contact with the floor causing her to hit her head and torso/back.
The nurse administered Lantus to resident at 8am instead of 8pm.

19. Points to Ponder
Use the Rule Book, Use the Rule Book, Use the Rule Book
Conduct a thorough investigation that addresses who, what, when, where, and how. A thorough investigation will help you determine the cause of undesired outcomes in your facility.
Medication errors are a widespread problem. Be diligent and provide oversight of staff who assist/administer medications.
When reporting to the department, report on time, be brief and concise, and proof read the report before submitting.