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SELF REPORTED INCIDENTS

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SELF REPORTED INCIDENTS How to Manage Them Effectively Leigh Grindley, RN, NHA Regional Vice President North Region LaVie Management Services Objectives ... – PowerPoint PPT presentation

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Title: 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
  1. Ensure that the resident/residents are safe.
  2. As soon as practicable, complete a thorough
    investigation to determine what occurred.
    Interview the resident, room mate, other
    residents, staff who witnessed the event.
  3. Assess the environment and equipment.
  4. Do not leave a stone unturned!!!

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

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

17
How do I keep my other residents safe
  1. Identify the other residents at risk and reassess
    them accordingly.
  2. Take credit for interventions implemented in the
    Residents charts assessment and care plan.
  3. Provide training to relevant staff immediately.
    Do not let staff work until they have been
    trained.
  4. 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 dont
    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
  1. Why did the kitchen aide not know that she was
    supposed to clean it?
  2. Because the Kitchen Supervisor had not trained
    her to do so.
  3. Why had the Kitchen Supervisor not trained her to
    clean the microwave.
  4. Because there were no cleaning schedules in place
    to clean the microwave.
  5. What is the root cause of the microwave not being
    cleaned
  6. 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 lt 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.
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