Every Staff MUST notify Josh Floyd - Quality Improvement/Risk Manager (JoshSunnyHaven@gmail.com)

 immediately for level 2 or 3 incidents. He has to enter them into CHRIS within 24 hours. This is EXTREMELY IMPORTANT

The Acknowledge form at the end (bottom of page) of this training is required

SERIOUS INCIDENTS 

Overview 

Incident Levels

The Virginia Department of Behavioral Health and Developmental Services (DBHDS) categorizes incidents into different levels based on their severity and impact on the individuals receiving services. A Level 1 incident is generally the least severe and includes events that are minor in nature, do not result in significant harm, and typically do not require extensive intervention. A Level 2 incident is more serious than a Level 1 incident but does not reach the severity of a Level 3 incident. Level 2 incidents typically involve events that have a moderate impact on the individual's health or well-being and often require more significant intervention and documentation. A Level 3 incident is the most severe category and involves events that result in significant harm or pose a substantial risk to the health, safety, or well-being of individuals.

Definition of a Level 1 Incident

Level 1 Incidents are events that:

• Have minimal or no impact on the individual's health or well-being.

• Do not require emergency medical treatment or hospitalization.

• Are often routine in nature and can be managed by staff with standard procedures and protocols.

• May involve minor injuries, minor behavioral incidents, or near-miss situations.

Examples of Level 1 Incidents

• Minor Injuries: Small cuts, bruises, or scrapes that can be treated with basic first aid.

• Behavioral Incidents: Minor behavioral issues such as verbal outbursts or non-aggressive actions that do not pose a threat to the individual or others.

• Near Misses: Situations where an incident could have occurred but was avoided through staff intervention or by chance.

• Medication Errors: Minor medication errors that do not result in harm or require significant medical intervention (e.g., a missed dose that does not impact the individual's health).

Reporting Requirements for Level 1 Incidents

While Level 1 incidents are less severe, it is still important to document them accurately to monitor patterns and prevent future occurrences. The DBHDS guidelines for reporting Level 1 incidents typically include:

• Documentation: All Level 1 incidents should be documented in the daily note as well as an Incident Report with Root Cause Analysis. This includes details such as the date and time of the incident, a description of what happened, who was involved, and any immediate actions taken by staff.

• Internal Reporting: These incidents should be reported to the appropriate supervisor or manager within the organization. This ensures that all incidents are reviewed, and any necessary follow-up actions are taken.

• Review and Analysis: Although these incidents are minor, they should still be reviewed periodically to identify any patterns or trends that could indicate underlying issues that need to be addressed.

Purpose of Reporting Level 1 Incidents

• Quality Improvement: Even minor incidents can provide valuable information for improving service quality and ensuring the safety and well-being of individuals.

• Proactive Measures: Documenting and analyzing Level 1 incidents helps organizations to be proactive in addressing potential issues before they escalate into more serious incidents.

• Compliance: Ensures that the organization remains compliant with DBHDS regulations and standards, which mandate the documentation and review of all incidents, regardless of their severity.

A Level 2 incident is more serious than a Level 1 incident but does not reach the severity of a Level 3 incident. Level 2 incidents typically involve events that have a moderate impact on the individual's health or well-being and often require more significant intervention and documentation. Here is a detailed explanation of what constitutes a Level 2 incident according to DBHDS guidelines:

Definition of a Level 2 Incident

Level 2 Incidents are events that:

• Have a moderate impact on the individual's health or well-being.

• May require medical attention beyond basic first aid but do not constitute a medical emergency.

• Often involve injuries, significant behavioral issues, or serious medication errors.

• Require detailed documentation and may necessitate a formal investigation.

Examples of Level 2 Incidents

• Injuries: Injuries that require medical attention, such as stitches, sprains, or minor fractures.

• Behavioral Incidents: Significant behavioral issues that pose a risk to the individual or others, such as aggressive behavior, self-harm, or property damage.

• Medication Errors: Serious medication errors that could have adverse effects but do not result in immediate harm requiring emergency treatment (e.g., administering the wrong medication that causes mild side effects).

• Hospital Visits: Non-emergency hospital visits or medical evaluations prompted by the incident.

• Allegations of Abuse or Neglect: Allegations that require investigation but do not involve immediate or severe harm.

Reporting Requirements for Level 2 Incidents

• Immediate Documentation: All Level 2 incidents must be documented promptly - in the daily note as well as the Incident Report with Root Cause Analysis. This includes detailed information such as the date and time of the incident, a thorough description of what happened, who was involved, and any immediate actions taken.

• Internal Notification: These incidents must be reported to supervisory or management staff within the organization. This ensures that appropriate steps are taken to address the incident and provide necessary support to the individual involved.

• External Reporting: Depending on the nature of the incident, it may need to be reported to external authorities or regulatory bodies, as required by DBHDS regulations. This could include notifying Adult Protective Services (APS) or Child Protective Services (CPS) if there are allegations of abuse or neglect.

• Investigation: A formal investigation may be initiated to determine the root cause of the incident, identify contributing factors, and develop preventive measures.

• Corrective Actions: Based on the findings of the investigation, corrective actions should be implemented to address any identified issues and prevent recurrence.

Purpose of Reporting Level 2 Incidents

• Ensuring Safety: Reporting and addressing Level 2 incidents promptly helps ensure the safety and well-being of individuals receiving services.

• Quality Improvement: Detailed documentation and analysis of these incidents contribute to continuous quality improvement efforts within the organization.

• Compliance: Adhering to DBHDS guidelines for incident reporting ensures that the organization remains in compliance with regulatory requirements, which is essential for maintaining licensure and accreditation.

• Accountability: Proper reporting and investigation of Level 2 incidents promote accountability and transparency within the organization, fostering a culture of safety and responsibility.

Definition of a Level 3 Incident

Level 3 Incidents are events that:

• Result in serious harm, injury, or death.

• Pose an immediate and substantial risk to the health, safety, or well-being of individuals.

• Require urgent medical attention or emergency intervention.

• Often necessitates a comprehensive investigation and reporting to multiple regulatory bodies.

Examples of Level 3 Incidents

• Severe Injuries: Major injuries such as broken bones, severe cuts requiring extensive medical treatment, or injuries resulting from violent behavior.

• Medical Emergencies: Life-threatening medical conditions or emergencies such as cardiac arrest, severe allergic reactions, or other critical health issues requiring emergency medical intervention.

• Deaths: Any unexpected or unexplained death of an individual receiving services.

• Allegations of Severe Abuse or Neglect: Serious allegations of abuse, neglect, or exploitation that result in significant harm or pose an immediate risk to the individual.

• Elopement: Instances where an individual goes missing and is at significant risk of harm due to their absence from a supervised setting.

• Critical Behavioral Incidents: Severe behavioral episodes that result in substantial harm to the individual or others, such as extreme aggression or self-injurious behavior requiring emergency intervention.

Reporting Requirements for Level 3 Incidents

• Immediate Action: Immediate action must be taken to ensure the safety and well-being of the individual and others involved. This may include contacting emergency services, providing first aid, or securing the environment.

• Prompt Documentation: Level 3 incidents must be documented promptly and comprehensively in the daily note as well as the Incident Report with Root Cause Analysis. Detailed information should include the date and time of the incident, a thorough description of what happened, individuals involved, witnesses, and immediate actions taken.

• Internal Notification: These incidents must be reported immediately to supervisory and management staff within the organization to ensure a coordinated response.

• External Reporting: Level 3 incidents must be reported to DBHDS and other relevant regulatory bodies, such as Adult Protective Services (APS), Child Protective Services (CPS), law enforcement, and licensing authorities, as required by law and regulation.

• Comprehensive Investigation: A thorough investigation must be conducted to determine the root cause of the incident, identify all contributing factors, and develop a detailed report of the findings.

• Corrective Actions: Based on the investigation's findings, comprehensive corrective actions must be developed and implemented to address the root causes and prevent recurrence. This may involve policy changes, staff retraining, or environmental modifications.

Purpose of Reporting Level 3 Incidents

• Ensuring Immediate Safety: Prompt reporting and response to Level 3 incidents are critical for ensuring the immediate safety and well-being of individuals receiving services.

• Regulatory Compliance: Adhering to DBHDS guidelines for reporting Level 3 incidents ensures compliance with state and federal regulations, which is essential for maintaining licensure and accreditation.

• Transparency and Accountability: Comprehensive reporting and investigation of severe incidents promote transparency and accountability within the organization, fostering a culture of safety and responsibility.

• Quality Improvement: Analyzing Level 3 incidents and implementing corrective actions contribute to continuous quality improvement efforts, helping to prevent similar incidents in the future.

• Josh Floyd - Quality Improvement/Risk Manager (JoshSunnyHaven@gmail.com)

  • First point of contact for all Serious Incidents

  • Frist point of contact  for RCA (Root Cause Anayalis) Questions

  • Frist Point of Contact for RCA and Serious Incident Reporting

  • Can also be reached at (540) 448-0893

  • Manages all Risk Assessments and Quality Improvement plans to keep SHRS in Compliance per DBHDS Guidelines.