715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of the facility policy and procedure manual, staff interview, and patient record review the facility failed to notify the Department within 48 hours following an unusual incident.
The findings include:
July 12, 2011 the facility policy and procedure manual was reviewed. According to the facility policy on unusual incidents..." Incidents with potential for negative community reaction or which may lead to community concerns. # 2. When all efforts to prevent a patient leaving Bowling Green Against Medical Advice have been exhausted every attempt will be made to arrange transportation out of the Kennett Square community. If the patients leaves and transportation arrangements are not possible, a Clinical Supervisor, Nursing Supervisor, or Executive Director after review of patient's history will make a clinical risk assessment and notify police of a potential risk without divulging confidential information.....The Unusual incident report will be filed with the Pa Department of Health Bureau of Drug and Alcohol Licensing within 48 hours of the following incidents: Complaint of patient abuse (physical, verbal, sexual, and emotional), Death or serious injury due to trauma, suicide, medication error or unusual circumstance, significant disruption of services due to disaster such as fire, flood, storm or other occurrence, potential for negative community reaction that may lead to community concern, drug related hospitalization of a patient."
In the client record reviewed, there was an incident report that documented the police were summoned to the facility on July 5, 2011 due to the patient being aggressive and belligerent towards staff after signing out of treatment against medical advice. The patient attempted to return to the property two times and became belligerent with staff on both occasions. The staff called 911 and police came to the facility to address the patient until the patient's ride arrived.
This is an event that could be a potential community concern. The facility failed to file an unusual incident report with the Department within 48 hours. An interview with the Facility Director confirmed that the report was not faxed to our department.
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Plan of Correction
Executive Director redistributed criteria for circumstances warranting a state incident report.
For every internal incident report that is written, the Director of Nursing and the Clinical Director will review against these criteria and execute a State Incident Report within 48 hours where warranted.
The Executive Director will be responsible for double checking all incident reports and assure those meeting the State Criteria were actually completed. |