Incident Reporting Policy

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Department: Residential Aged Care Description: Policy

Document Name: Incident Reporting Policy Issue Date: 11/12/2012

Adventist

Aged Care Document ID: RM-0001

Incident Reporting Policy

1. Introduction 2. Purpose 3. Scope

4. Legislative Obligations 5. Procedure

6. Documentation

Attachment A – Incident Management Instruction Guide Attachment B – Incident Classification Guide

Attachment C – External Reporting Obligation Guide

Attachment D – Roles and Responsibilities of Staff Members

REVISED BY: ECM AUTHORISED BY: CEO

Signed APPROVED BY: CEO

SECTION CHANGES IN THIS VERSION Initial Release 11/12/2012 Updated 11/03/2013

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1 Introduction

1.1 Adventist Aged Care will take all reasonably practicable steps to all reasonable efforts to report and where necessary investigate all incidents that adversely affect or have the potential to adversely affect the health, wellbeing or rights of our residents, staff members and volunteers.

1.2 Adventist Aged Care will investigate all incidents which we are obliged to investigate at law.

1.3 Adventist Aged Care will record, respond to and where necessary investigate all incidents reported in a transparent and timely manner and in accordance with obligations imposed by law.

1.4 Adventist Aged Care is committed to complying with our reporting obligations imposed by law and cooperating with external agencies in the investigation of reported incidents.

2 Purpose

2.1 The purpose of this policy is to:

(a) promote a high quality of care and services to all residents;

(b) provide a safe, fair and respectful workplace for staff members and volunteers;

(c) ensure timely and consistent escalation of incidents that affect or have the potential to affect the health, safety, wellbeing or rights of residents, staff members or volunteers to authorised

positions, including our managers and CEO;

(d) encourage timely and consistent recording, assessment and investigation of incidents to assist in the identification of opportunities for continuous improvement and the implementation of appropriate risk management strategies;

(e) ensure that incidents are reported in an accurate and timely manner to external authorities as required by law and/or under our internal policies and procedures; and

(f) ensure that incident data and analysis is used as part of a broader continuous improvement system.

3 Scope

3.1 This policy applies to all:

(a) staff members (including contracted agency staff) and volunteers; and

(b) incidents that are required to be reported under any State or Commonwealth law and under any of our internal policies and procedures.

4 Legislative obligations

4.1 Adventist Aged Care will take all reasonable steps to comply with the obligations (including reporting obligations) imposed under all legislation relevant to the delivery of services to our residents and relevant to the provision of a safe, fair and respectful workplace for staff members and volunteers.

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5 Procedure

5.1 Overview

This procedure outlines the requirements for the reporting and investigation of incidents that occur during the provision of services or accommodation at our residential aged care facilities, retirement villages and community aged care services.

In order to make the process of reporting incidents and conducting investigations into incidents as simple as possible, we have prepared an Incident Management Instruction Guide (see Attachment A).

Additionally, the roles and responsibilities of our staff members in relation to reporting and incident investigation are set out in Attachment D.

5.2 Incident Management Instruction Guide

The Incident Management Instruction Guide sets out the steps to manage an incident including:

(a) how to classify an incident (which will determine the size and scope of the investigation that is undertaken);

(b) our internal reporting obligations;

(c) our external reporting obligations; and

(d) who will be internally appointed to conduct an investigation and the time frame in which that investigation should be undertaken.

5.3 Incident Classification Guide

Immediately after an incident has occurred, the incident must be classified as a minor, moderate, major or extreme incident using the Incident Classification Guide at Attachment B.

The classification will be determined by the seriousness of the incident and will regulate the action that is to be taken both internally and externally in response to the incident including assessing the nature and extent of the investigation that will be undertaken.

If, after considering the Incident Classification Guide, there is any doubt about whether an incident is a minor, moderate, major or extreme incident, staff should immediately contact the facility manager or Executive Care Manager.

5.4 External Reporting Obligations Guide

The External Reporting Obligations Guide at Attachment C sets out our obligations to report particular types of incidents to external organisations.

It also identifies who internally is responsible to report the incident to any relevant external organisations.

5.5 Preserving the scene

If the incident occurred at our residential aged care facility service or in one of our retirement villages, action should immediately be taken to secure the area in which the incident

occurred which shall include:

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(a) isolating the area and the surrounds in which the incident occurred; and

(b) isolating any equipment that was being used in the events preceding the incident.

The area in which the incident occurred and any equipment which is isolated must remain isolated until such time as the investigation into the incident is complete (or in the event that an external statutory authority is also conducting an investigation, until such time as that external body confirms that alternative action can be taken).

However, if isolating the area or any equipment puts the health and safety of others at real risk and it is necessary to move the equipment or otherwise disturb the area, where possible, photographs should be taken before those things are disturbed.

5.6 Media

Under no circumstances is any staff member or volunteer to comment on or engage with the media.

Any media enquiries must immediately be directed to the Executive Care Manager or the CEO.

5.7 Summary of roles and responsibilities of staff members

Further information about the roles and responsibilities of staff members in relation to incident reporting and incident investigation are set out in Attachment D – Roles and Responsibilities of Staff Members.

5.8 Investigation of incidents

Investigations should be undertaken in a consistent and appropriate manner.

Major, extreme (and where necessary moderate incidents) must be investigated in accordance with the Incident Management Instruction Guide.

The size and scope of an investigation will vary depending on the severity and seriousness of the incident reported.

If there is a real or probable chance an incident will result in litigation, consideration should be given by the CEO and/or the Executive care Manager to consulting with our legal advisors.

If the incident is or is likely to be investigated by an external agency such as the police, the coroner or Workplace Health and Safety, the CEO and/or the Executive Care Manager will consult with that external agency (and our legal advisors) to decide whether our internal investigation should be deferred pending finalisation of the external agency’s investigation.

5.9 Continuous improvement

As part of our continuous improvement system we will collate and analyse incident data.

Monthly analysis of incidents will be generated to identify any trends in incidents.

Depending on the nature of the incident the facility manager and/or the Safety Coordinator are responsible for actioning trends identified in the monthly reports including:

(a) identification of improvement outcomes;

(b) identification of residents at risk of incidents;

(c) reassessment of residents’ needs as a result of individual incidents and where trends arise;

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(e) adjustment of staffing as appropriate;

(f) staff education and/or training; and

(g) maintenance and improvement of goods and equipment where required.

6 Documentation

6.1 To support and implement this policy and procedure we refer to related documentation including:

(a) Policies;

(b) Procedures;

(c) Forms;

(d) Internal documents; and (e) External documents.

6.2 Other relevant documents are:

(a) Incident Report Form;

(b) Hazard Report Form;

(c) Adventist Aged Care Incident Investigation Manual;

(d) Adventist Aged Care Policy and procedure – Work health and safety;

(e) Adventist Aged Care Procedure – Falls Management;

(f) Adventist Aged Care – Resident Falls Response Flow Chart; and (g) Adventist Aged Care – Elder Abuse Flow Chart.

Attachments:

Attachment A – Incident Management Instruction Guide Attachment B – Incident Classification Guide

Attachment C – External Reporting Obligation Guide

Attachment D – Roles and Responsibilities of Staff Members

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Attachment A – Incident Management Instruction Guide

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Attachment B – Incident Classification Guide

Minor Incident Examples

A minor incident includes:

• an incident that does not result in any injury to the person involved in the incident; and

• an incident that causes no permanent damage to any property.

• fire alarm;

• minor staff member performance issues (i.e.

continuously not completing set tasks);

• minor property theft or minor altercation between residents; or

• an incident which results in no injury to the resident.

Moderate Incident Examples

A moderate incident includes:

• an incident that causes minor injuries to the person involved in the incident;

• an incident that causes moderate property damage;

• a “near miss”;

• a resident fall; and

• a medication incident that does not result in harm to the resident.

• a staff member or visitor suffers a minor injury at work which does not require medical attention;

• a workplace health and safety incident which although resulting in no injury was a “near miss:’

• a resident had displayed sexual, physical or psychological behaviour that is not an immediate risk but had the potential to escalate without appropriate review and intervention;

• a resident suffers a minor injury such as a skin tear or bruise as a result of an incident;

• an unusual absence of a resident that is not reported to the police; or

• the incorrect administration of medication to a resident which does not result in harm.

Major Incident Examples

A major incident includes:

• a series of falls by the same resident ;

• a medication incident that results in harm to the resident.

• an incident that causes serious physical or psychological (though not life threatening) injury;

• an incident that results in serious property damage; and

• any damage to our reputation.

• a member of the catering staff suffers severe burns requiring immediate medical attention;

• a visitor attending the facility slips on a wet floor and hit their head requiring immediate medical attention;

• the incorrect administration of medication to a resident which has resulted in harm;

• a small contained fire or explosion or an infectious disease outbreak; or

• a fall by a resident.

Extreme Incident Examples

An extreme incident includes:

• a “reportable death”

• a life threatening physical injury to a resident or staff member;

• a missing resident reported to the police;

• an incident that causes very significant property damage; and

• an incident that causes (or has the potential to cause) very significant damage to our reputation.

• a staff member suffers a workplace injury resulting in a life threatening serious injury;

• a death of a resident which is suspicious or occurred in unusual circumstances;

• an unusual or unexplained absence of a resident, which has been reported to the police;

• alleged sexual misconduct by a staff member or a resident; or

• multiple chronic incidents.

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Attachment C – External Reporting Obligations Guide

Allegation / Event Notifiable

Authority Timeframe

Person Responsible for reporting

Allegation or suspicion of elder abuse (sexual contact,

unreasonable use of force or assault)

Department of Health and Ageing; and

Within 24 hours of allegation or

suspicion Executive Care Manager Police

Within 24 hours of allegation or suspicion

Allegation or suspicion of

financial abuse of a resident Police

As soon as provider forms a reasonable suspicion that there has been financial abuse.

Executive Care Manager

An unexplained absence of a resident at our residential aged care facility

Police

As soon as reasonably practicable

Executive Care Manager Department of

Health and Ageing

Within 24 hours after organisation reports the absence to the police

We, or a registered health practitioner forms a

reasonable belief that another registered health practitioner behaved in a way that

constitutes notifiable conduct (such as practicing in a way that constitutes a significant departure from accepted professional standards)

Australian Health Practitioner Regulation Agency

As soon as practicable after forming the reasonable belief

Death of a resident (if a

reportable death e.g. violent or unnatural death, suspicious or unusual circumstances)

Police; or

Immediately Executive Care Manager Coroner

A workplace incident that causes the death of a staff member or non-worker

Police; or

Immediately Executive Care Manager Coroner; and

Workplace Health and Safety; and Workcover

authority (if death of a staff member)

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Allegation / Event Notifiable

Authority Timeframe

Person Responsible for reporting A workplace incident resulting

in a person suffering a serious injury or illness including:

- an injury/illness which requires immediate treatment at a hospital;

- prescribed injuries such as a serious head injury, serious burn or spinal injury which require immediate treatment; or medical treatment within 48 hours of exposure to a substance.

Workplace Health and Safety

Queensland; and

Immediately Executive Care Manager

Workcover authority

A dangerous incident (e.g. a fire or explosion)

Queensland; and

Immediately Executive Care Manager Workcover

authority (only if the dangerous incident resulted in an injury to a staff member) A “near miss” that had the

potential to result in a serious risk to a person’s health or safety

Queensland

Immediately Executive Care Manager

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Attachment D – Roles and Responsibilities of Staff Members

Role Responsibility

CEO

• Authorises and delegates any potential media approaches and responses resulting from an incident (in consultation with the Conference General Secretary)

• Instructs legal advisors as necessary.

• Oversees the response to all extreme and major incidents.

• Ensures CEO is notified of all extreme and major incidents.

• Oversees the actions of the facility managers and staff to ensure they are complying with the incident reporting and management requirements as set out in this document.

• Undertakes a media risk assessment and potential response for the CEO’s consideration and refers all media interest regarding an incident to the CEO or Conference General Secretary.

Facility Manager

• Ensures the Executive Care Manager is notified of all extreme and major incidents.

• Oversees the actions of staff to ensure all incidents are reported and assessed and risk management strategies are identified and

implemented as required by this document.

• Ensures all relevant staff members are trained in and comply with incident reporting and management requirements.

• Takes all reasonably practicable steps to ensure that hazards are identified, reported, assessed and actioned.

• Ensures incident escalation timeframes are met as outlined in this document.

Senior nurse on duty at time of incident

• Ensures care staff and engaged persons comply with incident reporting requirements.

• Ensures incidents are escalated to appropriate levels within the timeframes outlined in incident reporting flowchart .

• Ensures people involved in the incident have access to relevant support services e.g. advocacy, legal support, police, medical services,

counselling services

• Consults with care staff and engaged persons to analyse and review incident information to identify practice issues and develop, implement and review improvement strategies where appropriate

Care staff on duty at time of incident

• Ensures incidents are escalated to appropriate levels within the timeframes outlined in incident reporting flowchart listed below.

• Responds to the immediate needs of people involved in the incident, including residents, staff and engaged persons and members of the public, contacts ambulance and/or other emergency services as appropriate and takes necessary action to re-establish a safe