TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: LONG-TERM CARE FACILITIES
PART 380 SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.530 INCIDENTS, ACCIDENTS AND EMERGENCY CARE
Section 380.530 Incidents, Accidents and Emergency Care
a) The facility shall have written policies and procedures for investigating, reporting, tracking and analyzing incidents, accidents and emergency care situations through the facility's management structure, up to and including the licensee and governing body representatives. The facility shall ensure that employees demonstrate their knowledge of and follow, these policies and procedures. A descriptive summary of each incident and accident affecting a consumer shall also be recorded in the progress notes for that consumer. For purposes of this Section, "serious" means any incident or accident that causes physical harm or injury to a consumer and requires medical treatment. Serious incidents, accidents and emergency care situations shall include, but are not limited to, the following:
1) Sexual assault;
2) Abuse, neglect or other maltreatment;
3) All deaths, including deaths of consumers who have been transferred to a hospital;
4) Medication errors that result in a consumer's unstable vital signs or referral to an emergency room;
5) Physical injury;
8) Missing persons after 24 hours;
10) Criminal conduct, including arrests and other interaction with police;
11) All hospitalizations, both medical and psychiatric;
12) All emergency department admissions, both medical and psychiatric; and
b) The facility shall notify the Department of any serious incident or accident requiring emergency care situations and every consumer death.
c) Any facility employee or agent who becomes aware of a serious incident or accident, emergency care situation involving a consumer, or becomes aware of a consumer death, shall report it immediately to the executive director. An executive director who becomes aware of the incident, accident or emergency care situation involving a consumer, or becomes aware of a consumer death, shall immediately report the matter by telephone and in writing to the consumer's guardian, the consumer's substitute decision maker, if any, any other individual designated in writing by the consumer, and the Department. The executive director shall report consumer allegations of abuse or neglect to the Department within 24 hours after the allegation is made.
d) The facility shall, by fax or phone, notify the Department central office within 24 hours after each serious incident, accident or emergency care situation. If a reportable incident, accident or emergency care situation results in the death of a consumer, the facility shall, after contacting local law enforcement pursuant to Section 380.550, notify the Department central office by phone only. For the purposes of this Section, "notify the Department central office by phone only" means talk with a Department representative who confirms over the phone that the requirement to notify the regional office by phone has been met. If the facility is unable to reach a representative during non-business hours, the facility shall notify the Department's toll free complaint registry hotline.
e) As soon as possible, but no later than 24 hours after the occurrence, the facility shall report any incident that is subject to the Criminal Code of 2012 to local law enforcement agencies.
f) The facility shall send a written narrative summary of each serious incident, accident or emergency care situation to the Department within seven days after the occurrence.
g) The facility shall maintain a log of incidents, accidents, or emergency care situations that are not considered to be serious because the consumer has not incurred physical or mental harm or injury requiring medical treatment, including all physical altercations involving a consumer and all threats of physical violence directed at a consumer or made by a consumer. The log shall be reviewed weekly by the facility's internal clinical quality assurance staff and shall be available to the Department upon request. The log shall include, at a minimum:
1) The name of the perpetrator;
2) The name of the victim, if any;
3) Any injury sustained by the victim;
4) A brief summary of the incident;
5) The number of prior incidents involving the perpetrator;
6) The number of prior incidents involving the victim;
7) Whether a physician (and whose physician) was called and any orders entered as a result; and
8) What the staff did to prevent recurrence of the incident.
h) The provisions under the Whistleblower Act shall apply to employees of facilities licensed under the Act.