Incident Reporting

By law, each staff member at OPG, Inc. must report any incident that has affected or could potentially affect a person’s health and safety. The Bureau of Developmental Disability Services (BDDS) provides a complete list of reportable incidents, which is outlined below. Additional details can be found in BDDS Incident Reporting and Management Policy.

BDDS Reportable Incidents

There are several types of reportable incidents, according to BQIS and BDDS. On this page, the reportable incidents are listed in different categories, which are:

Abuse, Neglect, Exploitation, and Mistreatment

  1. Physical abuse
  2. Sexual abuse
  3. Emotional/verbal abuse
  4. Domestic abuse, including but not limited to:
    • Physical violence;
    • Sexual abuse;
    • Emotional/verbal abuse;
    • Intimidation;
    • Economic deprivation;
    • Threat of violence; from a spouse or cohabitant intimate partner.
  5. Alleged, suspected or actual neglect
  6. Alleged, suspected or actual exploitation
  7. Any situation involving peer-to-peer aggression that results in significant injury by one individual receiving our services, to another individual receiving services.

Safety Concerns

  1. A service delivery site with a structural or environmental problem that jeopardizes or compromises the health or welfare of a person.
  2. A fire at a service delivery site that jeopardizes or compromises the heath or welfare of a person.
  3. Elopement of a person that results in evasion of required supervision as described in the ISP as necessary for the individual’s health and welfare.
  4. Missing person when a person wanders away and no one knows where they are.

Injury

A significant injury to a person that includes but is not limited to:

  1. A fracture;
  2. A burn, including sunburn and scalding, greater than first degree;
  3. Choking that requires intervention including but not limited to:
    • Heimlich maneuver;
    • Finger sweep; or
    • Back blows.
  4. Bruises or contusions larger than three inches in any direction, or a pattern of bruises or contusions regardless of size;
  5. Lacerations which require more than basic first aid;
  6. Any occurrence of skin breakdown related to a decubitus ulcer, regardless of severity;
  7. Any injury requiring more than first aid;
  8. Any puncture wound penetrating the skin, including human or animal bites;
  9. Any pica ingestion requiring more than first aid;
  10. Any injury to a person when the cause is unknown and the injury could be indicative of abuse, neglect or exploitation.
  11. Any injury to a person when the cause of the injury is unknown and the injury requires medical evaluation or treatment.
  12. A fall resulting in injury, regardless of the severity of the injury.

Restrictive Interventions

An emergency intervention for the individual resulting from:

  1. A physical symptom;
  2. A medical or psychiatric condition;
  3. Any other event.

Use of any physical or mechanical restraint regardless of:

  1. Planning;
  2. Human rights committee approval;
  3. Informed consent.

Medication Specific

A medication error or medical treatment error as follows:

  1. Wrong medication given;
  2. Wrong medication dosage given;
  3. Missed medication – not given;
  4. Medication given wrong route; or
  5. Medication error that jeopardizes a person’s health and welfare and requires medical attention.
  6. Use of any PRN medication related to a person’s behavior.

Other Incident Types

  1. Death (which must also be reported to Adult Protective Services or Child Protective Services, as indicated). Additionally, if the death is a result of alleged criminal activity, the death must be reported to law enforcement.
  2. Alleged, suspected or actual criminal activity by a person receiving services or an employee, contractor or agent of a provider, when:
    • The individual’s services or care are affected or potentially affected;
    • The activity occurred at a service site or during service activities; or
    • The individual was present at the time of the activity, regardless of location.
  3. Use of any aversive technique including but not limited to:
    • Seclusion (i.e. placing a person alone in a room/area from which exit is prevented);
    • Painful or noxious stimuli;
    • Denial of a health related necessity;
    • Other aversive technique identified by DDRS policy.

Internal Investigations

The Investigation Procedure is used to protect and ensure due process for each person supported and each employee when there are allegations of misconduct. Rationale: The Division of Disability and Rehabilitative Services and Bureau of Developmental Disabilities require that an Internal Investigation be conducted when allegations of Abuse, Neglect, or Exploitation by staff occur, when there are significant injuries of unknown origin, during Mortality Reviews, and as requested by BDDS/BQIS. BDDS also requires that employees being investigated in these situations be suspended during the investigation. Internal investigations are also considered to be best practice for addressing other instances of employee misconduct.

Types of Investigations

The same procedure is used for any type of investigation that occurs. The allegation is elevated to the Internal Investigation Team when it involves:

Following are the steps required to initiate and complete an Internal Investigation at OPG, Inc.

Receiving the Report

When an incident that may warrant an internal investigation is witnessed by or reported to you:

  1. Establish the safety of the person affected.
  2. Report the incident: Notify your supervisor or another member of management, including any member of the Internal Investigation Team, to initiate the investigation process. This notification may take the form of a face-to-face, phone, or text conversation or filing a complaint using the complaint procedure.
  3. Notify a member of the Investigation Team. The supervisor receiving a report will immediately elevate the concern to the assigned Lead Investigator.

Responding to the Report

  1. Employee Suspension:
    • Any employee, agent, or volunteer of OPG, Inc. will be removed from planned duties, with or without pay, immediately once allegations are received and for the duration of the investigation.
    • In some instances, OPG, Inc. may immediately terminate a staff member rather than conduct an internal investigation due to the nature, severity, and credibility of the allegation of ANEM or misconduct. The Executive Director of the department and/or any supervisor at OPG, Inc. are responsible for making this determination.
  2. Reporting and Notifications:
    • The Lead Internal Investigator will notify the appropriate authorities as needed, including APS or CPS, police if indicated, and the state by filing a BDDS Incident Report.
    • The Lead Internal Investigator will work with the CEO and CSO to determine what other notifications may need to be made.
  3. Investigation
    • The Lead Internal Investigator will conduct a prompt and fair investigation, lasting no longer than ten (10) business days.
      • The Lead Internal Investigator will gather evidence through interviews and a review of records, personnel, and personal files, as needed, to determine if a preponderance of evidence exists to support the allegations.
      • The investigator will interview all people involved in the allegation, including staff members, any people supported, the alleged perpetrator, any witnesses, and any other appropriate persons.
      • All people who were interviewed are required to produce a written, signed, and dated statement regarding the details of the investigation per state law.
  4. Findings and Recommendations
    • The Lead Internal Investigator will record the evidence and create a “Record of Findings and Recommendations” to the Chief Officers to determine the outcome of the investigation.
    • Findings
      • Substantiated: If most of the evidence supports the allegation, the allegation will be substantiated, or found to be true. The CSO and the Executive Director of the department will determine the extent of the disciplinary action which can include all actions up to and including termination of the employee. If the employee returns to work, they will not receive pay for the period of the suspension.
      • Unsubstantiated: If most of the evidence does not support the allegation, the allegation will be unsubstantiated. This means that there was insufficient evidence to support the allegation as true. The CSO and Executive Director of the department will determine any further action. All actions are recorded, and the training records are saved as part of the Investigation. If the allegation is unsubstantiated, the employee will receive pay for missed work during the investigation.
    • Recommendations
      • Recommendations may include suggestions for changes for the employee, the person supported, the department, and/or the organization as a whole.
  5. Follow-Up Actions
    • Supporting the Person Affected: If the allegation is substantiated or if the person supported seems to be experiencing trauma from the investigation process, OPG, Inc. will monitor and, when appropriate, provide trauma support to the person.
    • Improving Services: All investigations are reviewed regularly to determine if additional training of staff members would result in fewer investigations. The review occurs in the Executive Team regularly, the Quality Management Committee (QMC) annually, and the Board of Directors annually through data analysis of root causes and investigations. In the QMC and during Board meetings, the alleged perpetrator’s confidentiality will be upheld when necessary

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