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KBH Updated Critical Incident Reporting
Completing an incident report in Neo
August 24, 2023
Georgana Prudhomme, LCSW
Why Do We Report and Track Critical Incidents & Sentinel Events
KBH is licensed by DHHS, Office of Behavioral Health, and the Office of Child& Family Services and accredited by CARF which requires KBH to report incidents that fall into the categories of a Level I or Level II incident for adults which we will review in upcoming slides. OCFS has different reporting processes.
In tracking Critical Incidents and Sentinel Events, the KBH Quality team is able to create reports to assist with identifying any trends or concerned areas of services.
As mandated reporters, KBH staff are required to report alleged abuse: physical/sexual, emotional abuse to CPS and financial exploitation of a client. This includes:
Changes Made by The Office of Behavioral Health
• The Office of Behavioral Health created changes for the Level I and Level II reporting categories which we will review in more detail later in the slide presentation.
• These changes went into effect 7/1/22.
• Some categories have been altered, added or deleted.
• This presentation will review the types of event updated in the NEO Incident reporting form.
• You will see the changes and definitions provided as well.
What are Sentinel Events & Critical Incidents
• KBH is accredited by CARF and as one component of our accreditation is KBH tracks and follows Sentinel Events.
• Sentinel event is defined by CARF as an unexpected occurrence involving death or serious physical or psychological injury, or the risk there of death occurring from natural causes are not reported to CARF by the Quality Team.
• The Office of Behavioral Health (OBH) defines a critical incident as a serious event that creates significant risk of harm to clients, jeopardizes public safety or program integrity, and includes errors or undesirable events.
• For OBH, ALL client deaths must be reported including medical or death due to natural causes.
The NEO Critical Incident Report is used for tracking and reporting purposes and not intended to replace real time notifications that may be required in acritical situation.
• The NEO report is to be completed as soon as possible. Reporting incidents to your Supervisor, Administrator, Clinical Director, or Human Resources, for staff and/or client related injuries is required as well.
• If you are unsure if an incident requires reporting in NEO, you may consult with any of the above named persons.
• You may also contact the Clinical Training& Quality Manager for clarification of an incident.
KBH Reporting Timelines to Office of Behavioral Health OBH for Level I incidents
Level 1 Incidents for OBH:
Reported within 4 hours from when KBH staff learn about the event:
• Suicide
• Homicide
• Other Death – may be unknown at the time of the report.
• Clinical or Medication error resulting in emergency medical care for the client
• Lost, missing client or client that left the facility AMA in a residential/CSU placement which would rise to the level of Silver Alert and/or under the guardianship, in the Care and Custody of the Commissioner, and/or in violation to conditions of release/court order
• * Alleged abuse: physical/sexual, emotional abuse, neglect and financial exploitation of client by a staff. New category.
• Alleged Serious Crime (e.g., arson, assault, hostage) by client with extreme risk of harm to client, staff, or public
• Other serious events (fire, flood, motor vehicle accident in company vehicle with clients that requires medical attention for staff and/or client(s).
• Natural Disaster, building becomes uninhabitable, incidents that require client evacuation from the building
• *Medical Outbreak- is a new category. This relates to a medical outbreak that may close a program or office – or, if the majority of staff are out due to a medical outbreak in the same program and area.
What to do when you learn about a Client Death?
• Please send Sally Giddings an email noting the client ID number, initials, and if known, state how you were notified of the death and cause if known.
• This includes front desk staff as well as staff with direct service for the client.
• All deaths, either medical or undetermined, are reported to the appropriate DHHS department, such as OBH or OCFS.
• Complete a NEO CIR as soon as possible as a death needs to be reported within 4 hours of KBH learning about the death to OBH.
• Please provide as much detail as known in the NEO CIR.
• The Clinical Trainingand Quality Managerwill complete the reporting process.
• When a NEO CIR is entered, the Clinical Director, Clinical Training & Quality Manager & the Clinical Quality& Training Coordinator receive a NEO alert.
Level II Incidents
Reported within 24 Hours from when KBH staff learn about the incident:
• *New - Alleged Physical/Sexual, emotional abuse, and financial exploitation of client by someone other than a provider staff
• Suicide attempt that requires medical intervention
• Self-harm that requires medical attention
• Lost or missing client or client left the facility AMA in facility )PNMI residential/CSU Placement client (for more than 24 hours)
• Medication/Drug Diversion
• * New - Wellness Check
• Major Physical Plant Disaster
• This is a new Category OBH has added to the CIR reports ⬇️
• * Neglect – is a pattern of conduct, engaged in without the patient’s informed consent, resulting in deprivation of food, water, medication, medical services, shelter, cooling heating or other services necessary to maintain minimum physical or mental health.
• Examples :
• Malnutrition, Dehydration, Pressure sores, Unsafe or Unsanitary living conditions, Untreated medical problems or refusal of medical care, shelter, cooling or heating or other services to maintain minimum physical or mental health.
Children’s Critical Incidents
• If a report is made to Child Protective Services, we do not need to complete a NEO CIR form.
• Generally speaking Clinical Quality reports a child’s death, serious suicide attempt, or dangerous situation using the EIS system.
• If a client injury or other situation arises, if the incident occurred outside of KBH services at the time of the incident, we do not need to report these situations to OCFS. For example, if a client runs away and steals a car, it is not reportable to OCFS unless a KBH staff person was present providing services at the time of the incident.
How To Complete an Incident Report in Neo
• Please complete the form as soon as possible.
• In the event of an injury or EMS involvement, please report after everyone is safe.
• Please share this information with your staff in order to assist them in knowing what and how to report an Incident in NEO.
Search Incident Reports Screen:
Click on the Add button which will open the Incident Report window.
After selecting the type of event, note the date of the incident and not the date you are entering the incident. If you know the time of the incident enter it in the box shown below. Otherwise click the Unknown button. Note the Incidents are now listed in alphabetical order.
If you are a staff person, and are unsure which category to select, use the Incident Types Descriptions tab by click directly on the tab. This will bring up the Incident Type and Description text box to assist in determining what category to select. If you are still unsure which category to select, enter a category and the Clinical Quality team will make any needed corrections to a category selected.
The following are definitions provided in the Incident Type Description. Please note Medical has changed to Medical Event Emergent and Non-Emergent.
| Aggression/Violence | Client is aggressive or threatening violence towards a staff or other client/person while on KBH property |
| Alleged Abuse/Physical/Sexual/Emotional/Financial Exploitation of a Client (This is a new addition to the category) | Client, guardian or elder reports to staff there has been an incident of alleged sexual, physical abuse of a client or financial exploitation (adult focused). For children if event is reported to CPS it is not reportable in NEO. |
| Death | Death of a client as Suicide, Homicide or Unknown reasons. Report all client deaths. |
| Exposure to Communicable Disease | Document staff and/or client who are exposed to infectious diseases such as viral hepatitis-B, HIV, tuberculosis, etc. or if there is a Medical Outbreak in a KBH location or team. |
| Exposure to Potentially Biohazardous/Infectious Material | Client and/or staff experience a needlestick or have a non-intact skin or mucous membrane, exposed to blood, bodily fluid or other potentially infectious material. |
| Injury Including slips, trips and falls | A Client or Staff slips, trips or falls on KBH property. Report even if injuries are unknown. |
| Medical Event - Emergent | Emergent would be client or staff person experiences a life threatening emergency that requires immediate attention. |
| Medical Event - Non Emergent | Non Emergent would be a Medical Condition that does not require emergency services but does require medical attention. |
Definitions Continued. Please note Neglect is a separate Category; Psychiatric Event also has Emergent and Non-Emergent; and Self-Harm has been changed to include “requires medical attention.”
|
Neglect |
A pattern of conduct, engaged without the patient's informed consent resulting in deprivation of food, water, medication, medical services, shelter, cooling/heating or other services necessary to maintain minimum physical or mental health. |
| Other | This box is used when the staff person is unsure which box to check. |
| Other Serious Events | Used when an incident does not fit into one of the other categories - but is believed to be a serious event. |
|
Property Damage |
Fires, floods, natural disasters, long term power outage, or uninhabitable for KBH or client. Client or staff damages KBH property. Or a client of a KBH building is unhabitual. |
| Psychiatric Event – Emergent |
Emergent would be a client or staff person experiences a serious mental health crisis that requires immediate intervention including Emergency Services. |
| Psychiatric Event - Non Emergent |
Non Emergent would be a serious mental health crisis that requires attention but is not require emergency services. |
| Self-Harm that requires medical attention | Used when a client harms him/herself to the point that medical attention is needed. |
|
Serious Crime |
Serious Crime (arson, assault, hostage) by client with extreme risk of harm to client, staff, or public. |
Please note that Sexual Assault is a separate stand alone category. Wellness Check is a new additional category.
| Sexual Assault |
This is a separate category from alleged abuse as Sexual Assault is used when a client reports any form of sexual assault. |
| Suicide Plan/Attempt that requires medical attention | When a client makes a Suicide Attempt that requires medical attention. No longer report suicide plans. |
| Unauthorized Use or Possession of Legal or Illegal Substances |
Used for client and/or staff who have illegal substance on KBH premises or are under the influence of substances. |
| Use and Unauthorized Posession of Weapons | Used when a client or a staff person brings a weapon onto KBH property which may include a gun, machete, bomb or other items deemed as a weapon. |
| Use of Seclusion/Restraint | Used when a staff member holds or places a client in seclusion or a restraint. |
| Vehicular Accident |
MVA in company vehicle with clients that requires medical attention for staff or client(s). |
| Wandering/Elopement | When a client leaves a KBH facility AMA - PNMI, residential/CSU placement for client for more than 24 hours. Or if the client is under Guardianship, in the Care & custody of the Commissioner, and/or in violation of conditions of release/court order, OR, Lost or Missing client or client left the facility AMA - PNMI, residential/CSU placement for client for more than 24 hours |
| Wellness Check |
Used anytime KBH staff requests a Wellness Check by local authorities to check on the well being of the client(s). |
Add the Client ID & the Information will Auto Fill. Enter the Provider in the box designated below. If the incident involves additional staff use the Add New Provider box marked below.
When you select a provider if the box did not pre-populate, you will select a provider or enter the provider type; agency, even if KBH; Clinician/Staff; Program; and Save. If you have notified other staff please click the box for informed.
Summary Section
• In this section you will enter what occurred. Please add enough information in the Summary textbox to make it clear as to what occurred, who was involved, and any other relevant information, in order to assist the Clinical Training & Quality Manager or Administrators, in reporting the incident. Providing clarity here is important in capturing a picture or understanding of what the incident involved when we report the incident.
• For example, Client’s sister called Jane at the Med Clinic to report the client passed away last night.
• If this is a staff incident, state what occurred.(Please note all staff injuries are handled by Human Resources)
• For example, Jane Doe twisted her ankle coming down the stairs, missing the last step and is limping with a swollen ankle.
Outcomes Text Box
• In the Outcomes text box please document what you know happened after the incident Summary has been completed, if known.
• In an incident Summary section, an example may be: a client report she took 50 Tylenol in a suicide attempt and then told his partner.
• The Outcome may be that his partner called 911; EMS arrived; and took him to the MGMC ER for treatment. His partner met him in the ER and stayed until he was admitted to the unit.
• In the staff injury, you may document if the person left for medical care; or consulted with HR; and if it was recommended the staff person go to Employee Health. No details about the injury are documented here.
The Admin Response Text Box
• The Admin Response text field should be left blank by the staff person entering the incident report.
• The Clinical Quality &Training Manager, Supervisor, Director, or Administrator can use this field to note any actions taken, if necessary.
• In this text field the Clinical Training & Quality Manger documents actions taken re: reporting the incident to OBH or the Office of Child and Family Services(OCFS).
• Once the Incident is submitted you will no longer be able to see the incident.
Submitting the Form
• Once you have entered the Client ID; client’s providers; documented what occurred in the Summary; and, if you have information to document re: outcomes; next, you will select your supervisor in the drop down menu and Send the form. Then you select your supervisor and click Submit.
• Clinical Quality receives a notification when an incident is submitted. The incident is reviewed and actions taken appropriate for the information presented. The Incident will be sent to the supervisor or Administrator, who will submit the form after reviewing the case.
That is how you successfully submit a NEO Critical Incident Form.
• Questions – If you have any questions re: using this form, please speak with your Supervisor, Director, or Administrator.
• For back-up, you may contact Georgana Prudhomme, LCSW, at gprudhomme@kbhmaine.org
• When Georgana is out of the office, Jody Bucknam is the back up contact at jbucknam@kbhmaine.org