5122-3-13 Regional psychiatric hospital (RPH) incident reporting rule.

(A) Purpose.

The purpose of this rule is to establish standards and procedures to ensure that prompt and accurate reporting; immediate evaluation; implementation of corrective and remedial action; and preventative measures take place with the occurrence of each incident. Effective incident reporting provides each hospital with individual and cumulative incident report data to find problem areas and implement corrective measures designed to prevent recurrence and manage risk. Analysis of this data can reveal system issues and problems in need of corrective action.

(B) Applicability.

The provisions of this rule shall be applicable to all hospital inpatient and community support network (CSN) programs under the managing responsibility of the department. Subject to this rule, all occurrences during an inpatient stay or within thirty days of discharge must be recorded in the patient care system regardless of other reporting requirements (i.e., the joint commission, department of health, etc.).

(C) Definitions.

The following definitions shall apply to this rule in addition to those appearing in rule 5122-1-01 of the Administrative Code:

(1) "Absent without leave" or "AWOL" means a patient has breached the secure perimeter of the hospital without permission, has eloped during, or has not returned from an authorized absence from the facility. The reporting of AWOLs is determined in paragraph (D)(6) of this rule.

(2) "Abuse" means any act or absence of action caused by an employee inconsistent with rights which results, or could result in physical injury to a patient; any act which constitutes sexual activity, as defined under Chapter 2907. of the Revised Code, where such activity would constitute an offense against a client under that chapter; insulting or coarse language or gestures directed toward a client which subjects the client to humiliation or degradation; or depriving a patient of real or personal property by fraudulent or illegal means.

(a) There are five sub-types of abuse: physical, verbal, sexual, neglect, and defraud. If there are multiple sub-types to an incident, only select the most severe sub-type when recording an incident. For example, if a patient alleges both physical and verbal abuse, code the allegation as "physical." All incidents of abuse are "major."

(b) When recording "alleged abuse," the staff person alleged to have committed abuse shall be coded as "perpetrator" and the patient as "victim."

(c) Frequent allegations of sexual abuse shall be investigated, but need not be reported as incidents unless such allegations are founded. However, record of the allegations and subsequent investigations shall be recorded in the clinical record and addressed in the treatment plan.

(3) "Accident" means any incident that results from an unintentional occurrence.

(a) There may or may not be injuries associated with an accident. When an injury or injuries occur, the following codes shall be utilized to classify the accident:

(i) Patient or staff injury resulting from a restraint which requires more than first-aid is a "major" incident.

(ii) Patient or staff injury needing no treatment or first-aid is a "minor" incident.

(iii) Patient or staff injuries needing medical treatment may be "minor" or "major," depending on the severity.

(b) Unexpected hospitalization (including observation) resulting from an accident is a "major" incident.

(c) All "accident/falls" and "accident/choking on food" with or without injuries shall be considered as reportable incidents as defined in paragraph (C)(20) of this rule.

(d) When recording an "accident," staff shall indicate whether the accident was observed or not observed by staff.

(4) "Assault" means to knowingly or recklessly cause or attempt to cause physical harm to another. Assault is distinct from a threat, in that assault is an actual attempt to cause physical harm instead of a statement alluding to such action. An allegation of an employee assaulting a patient shall be reported as "alleged abuse." Assault includes all types of physical aggression except when further defined under "abuse."

Assault has four sub-types: sexual, physical, weapon, and other.

(a) All physical assaults resulting in the need for admission to a general hospital shall be classified as "major" incidents. Physical assaults requiring more than first-aid and less than admission to a general hospital shall be classified as "major" or "minor" at the discretion of the CEO. Physical assaults requiring less than first-aid shall be classified as "minor" incidents.

(b) All weapon assaults shall be classified as "major" incidents.

(c) An allegation of sexual assault that involves non-consensual sexual conduct shall be further classified as rape. A rape allegation shall be reported as a "major" incident.

(d) Frequent allegations of sexual assault resulting from fixed delusions shall be investigated, but need not be reported as incidents unless the allegations are founded. However, record of such allegations and subsequent investigation shall be recorded in the clinical record and addressed in the treatment plan.

(e) When two persons are fighting and it is unclear or unknown who started the fight, both persons shall be coded as "perpetrators." Otherwise, individuals involved shall be coded either "perpetrator" or "victim" as appropriate. Of the persons involved, the one with the highest level of injury determines the incident status ("major" or "minor") for the whole incident.

(5) "Attempted suicide" means an unsuccessful attempt to end one's own life with a finding of intent as determined by a clinician.

(a) Attempted suicide is a "major" incident.

(b) Suicidal thoughts should not be reported as incidents but should be documented in the patient's chart.

(c) When recording attempted suicide, the patient should be coded as "victim."

(6) "Chief clinical officer" or "CCO" means the medical director of an RPH as defined in division (K) of section 5122.01 of the Revised Code.

(7) "Chief executive officer" or "CEO" means an individual who directs and oversees the operation of an RPH.

(8) "Confirmed abuse/neglect" means an allegation of abuse or neglect has been proven to have occurred.

(9) "Contaminated/unknown sharps injury" (i.e., needle sticks, etc.) means the injury of any person involved. Those at greater than first-aid may be considered a "major" incident depending upon severity, and all others are "minor" incidents.

(10) "Contraband and restricted/controlled items" means those items that are not permitted on state property pursuant to law or hospital policy. The following shall be considered contraband:

(a) All weapons or potential weapons including, but not limited to, guns, knives, electronic control devises such as tasers and stun guns, defensive aerosol sprays, ammunition and explosives;

(i) If weapons or potential weapons are brought onto or found on state property, the incident shall be reported as "major." Firearms or electronic control devices in the possession of peace officers shall not be reported unless such items are brought onto patient units;

(ii) Discharge of a weapon or electronic control device on RPH property is considered a "major" incident;

(iii) Intoxicating beverages and illicit drugs including, but not limited to, non-prescribed prescription drugs and illegal drugs; and

(iv) Stolen articles.

(b) If police arrest an individual for possession of contraband or restricted/controlled items, the incident shall be considered "major." Possession of other contraband and restricted/controlled items shall be considered "minor" incidents unless stated otherwise in this rule.

(11) "Critical major incident" means an event for which there is a need to immediately advise the deputy director of hospital services, the ODMH medical director and the ODMH director of the situation. These include, but are not limited to, death; rape; injury which may result in permanent loss of functioning; AWOL of a forensic patient; AWOL of a patient whose life may be endangered because of weather, illness, poor judgment, or other conditions; power failure which is not quickly resolved; loss or exposure of personal health information (PHI); fire (at the discretion of the CEO); and all sentinel events as defined in rule 5122-2-25 of the Administrative Code.

(12) "Death" means the death of a patient while on hospital rolls or within thirty days of discharge.

(a) If type of death is unknown, select "pending."

(b) The person who dies should always be coded as the "victim."

(c) Death is a "major" incident if the person died while an inpatient, or within thirty days of discharge. If death was a result of suicide or other non-natural causes while an inpatient, or within thirty days of discharge, it is a "critical major" incident.

(13) "Equipment or utility failure or malfunction" means any unplanned malfunction or failure of essential utility systems including, but not limited to: electrical power distribution; plumbing (water and waste disposal); natural gas; emergency power (generators); elevators; air-conditioning (HVAC); boilers; and communications or patient care/medical equipment (including ADMs) that do not function according to their designed purpose and could result in a potentially unsafe situation for patients, staff and visitors.

(a) Equipment or utility failure which requires a repair in excess of one thousand dollars; having a significant impact on the operation of the RPH (as determined by the CEO or designee); or requiring the evacuation of a building shall be coded as a "major" incident.

(b) Other instances shall be considered "minor" incidents.

(14) "Fire" means the burning of a solid, liquid, or gas that must be extinguished to prevent the spread of the fire or smoke from endangering patients, staff, visitors, or buildings.

(a) Any fire that results in an injury, a fire department response to extinguish, or an evacuation of a building is a "major" incident.

(b) Other types of fires shall be considered as "minor" incidents.

(15) "Illicit use or possession of drugs or alcohol" means that a person is suspected of or actually under the influence of alcohol or drugs.

(a) If the person is arrested, the incident is "major."

(b) All other incidents shall be considered "minor."

(16) "Illness or medical emergency" means physical illnesses such as infections, kidney problems, cardiac emergencies, etc., which require treatment outside the RPH.

(a) Unexpected hospitalization (including observation) due to illness or medical emergency is a "major" incident. However, if a person is examined and treated and sent back to the RPH without being admitted, the incident shall be considered "minor."

(b) Scheduled trips or admissions to other medical facilities for planned medical or surgical interventions are not reported as illnesses or medical emergencies.

(17) "Inappropriate sexual behavior" means public masturbation, sexual touching, inappropriate kissing, making repeated or targeted inappropriate sexual comments, sexual advances, and attempts to have or to have had sexual intercourse by any person. Non-consensual sexual intercourse is classified as "rape."

(a) If a staff person is involved as the perpetrator against staff, visitors, or others, the incident is "major."

(b) Staff-to-patient inappropriate sexual behavior is considered "patient abuse."

(c) If a patient, visitor, or other is involved as the perpetrator, the incident may be considered "major" at the discretion of the CEO/designee.

(18) "Incident" means any occurrence which is not consistent with the routine care of a patient, the routine services provided by the hospital, or the routine standard of care for the hospital. Incidents may involve patients, employees, visitors, and other persons as further specified in this rule. Incidents involving patients are not restricted to those occurrences on the hospital's premises. Also included is any patient who is on the rolls of the hospital and is involved in an incident while away from the hospital.

(19) "Injury to staff while restraining a patient" means injury to any employee while in the process of restraining a patient, or while the patient is in seclusion and restraint. This category includes any injuries sustained in an accident that occurred as a direct result of responding to a restraint event.

(a) All injuries requiring more than first-aid as a result of restraint are "major."

(b) Injuries needing no treatment or first-aid are "minor."

(20) "Major incident" means an occurrence severe enough to warrant special categorization for purposes of reporting and includes the following:

(a) Injury or illness which results in admission to a general hospital;

(b) Attempted suicide;

(c) AWOL as further defined in paragraph (D)(6) of this rule;

(d) Property damage, loss, or theft valued at more than one thousand five hundred dollars;

(e) Injury occurring during the course of restraint that requires more than first-aid;

(f) Medication errors of level five or six;

(g) Abuse;

(h) Assault resulting in admission to a general hospital; or rape; or weapon assault;

(i) Death;

(j) Weapons or potential weapons brought onto or found on state property;

(k) Discharge of a weapon or electronic control device on RPH property;

(l) Arrest of an individual for possession of contraband or restricted/controlled items;

(m) Inappropriate sexual behavior by a staff person against staff, visitors, or others; or neglect of patients;

(n) Threats toward specific public officials; bomb threats that require the evacuation of a building; or threats sufficient to warrant a warning as found in section 2305.51 of the Revised Code, and rule 5122-3-12 of the Administrative Code ("Duty to protect");

(o) Missing medication which requires a police investigation;

(p) Any incident requiring an outside police investigation;

(q) Unauthorized use of restraint;

(r) Any fire resulting in an injury, a fire department response to extinguish, or an evacuation of a building;

(s) Illicit use of alcohol or drugs resulting in an arrest;

(t) Anything judged by the CEO as being a "major" incident;

(u) Equipment or utility failure which requires a repair in excess of one thousand dollars; has a significant impact on the operation of the RPH (as determined by the CEO or designee); or requires the evacuation of a building; or

(v) Any violation where an outside agency is notified, or for a potential violation of existing workplace violence policy(ies) of the department.

(21) "Medication error" (also called "medication variance") means any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to: professional practice; health care products; procedures and systems, including all aspects of prescribing (i.e., order communication, product labeling, packaging, nomenclature, compounding and dispensing, distribution, administration, education, monitoring and use). Medication errors are assigned a severity level based on ODMH policy MD-03, "Medication Errors."

(a) All medical errors of level five or six are "major" incidents.

(b) Medication errors of level zero through four are not considered incidents but should be documented pursuant to ODMH policy MD-03, "Medication Errors."

(22) "Minor incident" means those types of occurrences which do not appear to be severe or detrimental to the best interests of the patient, department, RPH or personnel.

(23) "Missing medication" means an incident where medication is unaccounted for, such as when a patient returns from authorized leave without the medication with which they were provided; or when controlled medications are missing from the ADM machines after the count has been reconciled.

(a) All incidents requiring police investigation are "major."

(b) All other incidents are "minor."

(24) "Neglect" is defined in rule 5122-3-14 of the Administrative Code as "a purposeful or negligent disregard of duty imposed on an employee by statute, rule, RPH policy, position description, or professional standard and owed to a client by that employee." Responses to allegation of abuse or neglect shall be consistent with the requirements of rule 5122-3-14 of the Administrative Code.

(25) "Office of quality assurance and improvement" means the office of quality assurance and improvement of ODMH.

(26) "Other" means the classification of an incident when no other incident type appropriately describes an incident.

(27) "Patient care system" or "PCS" means the official secure centralized ODMH automated database where patient demographic and related information is maintained.

(28) "Policy violation (staff only)" means any act where staff has perpetrated an incident and no other incident type appropriately describes the incident. When recording this type of incident, one must record the policy violated as well.

(a) Any violations where an outside agency is notified or the workplace violence policy potentially has been violated are "major."

(b) All other incidents may be "major" or "minor" incidents depending upon the severity of the incident as determined by the CEO or designee.

(29) "Program" means any service provided by ODMH employees.

(30) "Property damage" means accidental damage to property, but may also include damage due to negligence or intentional acts by entities outside the hospital. For example, a falling tree that hits a car; damage due to patient behavior; and vandalism constitute property damage.

(a) Property damage greater than one thousand five hundred dollars or that has a significant impact on the operation of the organization (as determined by the CEO or designee), or that requires the evacuation of a building are "major" incidents.

(b) All other property damage incidents are "minor."

(31) "Property loss" means accidental or negligent loss of department or state of Ohio property. If the value of the property is greater than one thousand five hundred dollars, or involves a loss of protected health information, the incident is "major." All other property loss incidents are "minor."

(32) "Self-injurious behavior" means an act of self-induced bodily harm that is not intended to kill oneself.

(a) Injury of any person involved at greater than first-aid should be considered "major."

(b) Injuries needing only first-aid are "minor" incidents.

(33) "Sentinel event" means an event defined in rule 5122-2-25 of the Administrative Code.

(34) "Theft" means the taking of another person's property without the person's permission or consent. Allegations of theft of patient property by employees should be reported as "major" under "alleged patient abuse."

(a) Any theft of property which constitutes a substantial value as determined by the CEO or designee, in consultation with the department's security consultant, is a "major" incident.

(b) The theft of property which is not considered of substantial value is a "minor" incident.

(35) "Threat" means behavior meant to intimidate a person such that there is a reasonable fear of bodily harm through the use of threatening words and/or conduct without use of a weapon or actual physical attack. Threats include, but are not limited to, bomb threats, threats of aggression or violence, threats against public officials, spousal threats thought to be serious, stalking, and menacing.

(a) Threats towards specific public officials, bomb threats that require the evacuation of a building, or threats sufficient to warrant a warning as found in section 2305.51 of the Revised Code and rule 5122-3-12 of the Administrative Code ("Duty to Protect") are "major" incidents.

(b) Others are "minor" incidents.

(36) "Unauthorized movement" or "UM" means any incident where the patient has been absent from a location, within the facility defined by the patient's privilege status regardless of the patient's leave or legal status. A patient should be considered UM if the patient has not been accounted for when expected to be present. Implicit in this definition is the notion that the patient has been informed of the limits placed on her/his location or movement prior to the UM incident. All UM incidents are considered "minor."

(37) "Unauthorized use of restraint" means instances where hospital policies and procedures were not followed in authorizing the use of seclusion or restraint. All instances are considered "major" incidents.

(38) "Unfounded abuse/neglect" means that an allegation of abuse or neglect was not supported by evidence upon investigation.

(39) "Unproven abuse/neglect" means it could not be proven that the incident did or did not happen. There may have been conflicting or inadequate evidence to either prove or disprove that the abuse/neglect occurred.

(D) Reporting of incidents.

(1) All incidents shall be documented and reported in accordance with the provisions of this rule and on the forms and database prescribed by the department.

(2) Investigation of incidents.

(a) The CEO shall develop an investigative procedure to be followed by employees in response to the occurrence of all incidents.

(b) Based on the severity of the occurrence, some incidents shall be reported to central office as defined in paragraphs (D)(4) to (D)(7) of this rule.

(3) Incidents classified as "major";

(a) Major incidents shall include, but not be limited to the following:

(i) All sentinel events;

(ii) All deaths. In addition, the following deaths shall be reported immediately to the coroner and the Ohio state highway patrol:

(a) Suicide;

(b) Accidental death regardless of cause;

(c) Apparent or possible homicide; and

(d)Any suspicious or unusual death.

(iii) Events determined by the CEO or designee and/or CCO or designee that require the immediate investigation by the local law enforcement agency and/or the Ohio state highway patrol. Examples include:

(a) Serious injury caused by another person, whether another patient, employee, or any other person;

(b) Alleged criminal act of an employee committed on hospital grounds or while performing occupational duties off-grounds which may result in a felony or misdemeanor charge;

(c) Alleged criminal act of a patient which may result in a felony or misdemeanor charge; and

(d)Alleged criminal act on RPH grounds by person other than an employee or patient which may result in a felony or misdemeanor charge.

(iv) Severe weather conditions resulting in the disruption of the normal operation, safety, and/or security of the RPH; and

(v) All "major" incident types as further defined in paragraph (C)(20) of this rule.

(4) General reporting requirements.

(a) The employee who discovers or witnesses an incident, or to whom an incident is reported, is responsible for documenting the incident, cooperating in the investigation, and providing the investigating officer or staff with a complete statement or statements as needed.

(b) The incident notification report (DMH-ADM-005a or DMH-CSN-008, as appropriate) required by ODMH shall be completed for each incident. Each CSN also has additional reporting responsibilities utilizing form DMH-0484/LIC-015.

(c) Facts regarding the incident shall be reported in writing. No unsubstantiated conclusions, opinions, hearsay, assumptions, or accusations shall be included in the incident report.

(d) The incident report shall not be filed, nor references to an incident report made, in the patient medical record. However, those events which have a direct medical or clinical effect on the patient should be recorded in the patient medical record. The incident report shall be maintained in an administrative file. The CEO shall utilize a procedure for the filing and internal management of incident reports.

(e) Incident reports shall be maintained in a confidential manner and be accessible only to authorized employees except by consent of the CEO in consultation with the department's legal office.

(i) The Ohio state highway patrol may have access only to the incident notification report form (DMH-ADM-005a) or the CSN incident notification report form (DMH-CSN-008) upon request.

(ii) If requested, the local mental health board only shall have access to information on the incident notification report form (DMH-ADM-005a) or the CSN incident notification report form (DMH-CSN-008).

(f) The CEO shall designate a person to be responsible for notifying the parents, spouse, legal guardian, or legal custodian of a patient about the occurrence of an incident involving a patient. This disclosure shall require the consent of the patient except if the patient is deceased, AWOL, or unconscious.

(g) The CEO shall develop a policy that determines which hospital staff are to be notified of the occurrence of incidents.

(5) Immediate reporting to central office.

(a) Utilizing the telephone call-in procedure defined in ODMH policy I-05, ("Central Office Administrative Officer of the Day"), the CEO or designee shall report at all times, the occurrence of any of the following major incidents to the deputy director of hospital services.

(i) All deaths;

(ii) AWOL of a patient as defined in paragraph (D)(6) of this rule;

(iii) Fires, as defined in paragraph (C)(14) of this rule;

(iv) Equipment or utility failure or malfunction as previously defined in paragraph (C)(13) of this rule that may result in significant potential danger, as determined by the CEO or designee, to staff and/or patients (i.e., loss of fire alarm or suppression systems, telephone service, emergency generator, or water/sanitary systems);

(v) Other incidents, as determined by the CEO or designee, that are critical in nature and may result in significant danger to staff and/or patients (i.e., a hostage situation, a flood, severe weather conditions, bizarre or unusual crimes or events); and

(vi) Any incident, as determined by the CEO or designee, that would likely result in news media coverage.

(b) All incidents that involve a morbidity, mortality, or reviewable sentinel event, as defined in rule 5122-2-25 of the Administrative Code, "Morbidity, mortality, and sentinel event," shall be reported to the ODMH medical director or designee by the hospital CCO or designee via telephone or email.

(c) For incidents listed in paragraphs (D)(5)(a) and (D)(5)(b) of this rule which occur between five p.m. and eight a.m. Monday through Friday and all day on weekends and holidays, the CEO or designee shall contact the ODMH administrator on duty pursuant to ODMH policy I-05, ("Central Office Administrative Officer of the Day").

(6) AWOL reporting procedure.

(a) AWOLs are reportable to central office as either "minor," "major," or "critical major" incidents. All AWOL data shall be tracked internally by RPH procedures and monitored through quality improvement activities. Incident reports involving AWOLs shall include the time and date the patient eloped, when the patient was returned (or discharged), location where found, and a description of all activity that may have occurred while the patient was AWOL.

(b) AWOL as a "critical major" incident.

The following AWOLs are considered reportable as "critical major" incidents.

(i) AWOL of patients considered at risk to self or others for which, because of their psychiatric history, criminal history, legal status, immigration status, or current psychiatric condition or behavior, there is a need to notify state or federal law enforcement (i.e., Ohio highway patrol, federal marshal's office, FBI, secret service, or homeland security, respectively); or

(ii) Any AWOL not identified in paragraph (D)(6)(b)(i) of this rule that the hospital's CEO, designated AoD or deputy director deems to be reported as such (i.e., imminent threat to self or others, extreme adverse weather conditions, fragile medical status, etc.);

(iii) The RPH CEO or designee shall report an AWOL that is considered to be a critical major incident to the ODMH hospital services deputy director immediately upon discovery. The deputy director may be reached by calling the twin valley behavioral healthcare Columbus switchboard at 614-752-0333. Alternatively, the reporting CEO or designee may contact the deputy director through the cell phone.

(c) AWOL as "major" incident.

When a patient falls under a certain legal status, or meets specific criteria, the incident is reportable as a "major" incident to central office. These incidents fall within the following categories:

(i) Forensic AWOL: all patients with a forensic legal status or tracked as forensic and listed in the following divisions and sections of the Revised Code:

(a) 2945.371(G)(3) - competency evaluation;

(b) 2945.371(G)(4) - sanity evaluation;

(c) 2945.38(B) - IST-R;

(d) 2945.38(H)(4) - IST-U;

(e) 2945.39(A)(2) - IST-U-CJ;

(f) 2945.401 - IST-U-CJ-CR;

(g) 2945.40 - NGRI ;

(h) 2945.402(A) - NGRI-CR;

(i) 2967.22 - parole/probation;

(j) Police hold/capias; or

(k) Jail transfer.

(ii) Risk of harm to self or others: All patients who, in the judgment of the CCO, are the following:

(a) At risk of harming self or others;

(b) Currently held on an emergency certificate under section 5122.10 of the Revised Code;

(c) Adjudicated at risk by a probate court under division (B) of section 5122.01 or division (C) of section 5122.15 of the Revised Code.

(iii) The RPH CEO or designee shall report an AWOL that is considered to be a major incident to the ODMH hospital services deputy director immediately upon discovery. The deputy director may be reached by calling the twin valley behavioral healthcare, Columbus switchboard at 614-752-0333. Alternatively, the reporting CEO or designee may contact the deputy director anytime through the cell phone.

(d) AWOL as a "minor" incident.

An AWOL that does not fall under the classifications described in paragraphs (D)(6)(b) and (D)(6)(c) of this rule shall be considered a "minor" incident, (i.e., a voluntary patient who is not considered at risk to self or others). RPHs shall be responsible for maintaining information about AWOLs classified as "minor" incidents but no telephone reporting to central office is required.

(e) Notice of discharge requirements for forensic patients.

In accordance with division (A) of section 5122.26 of the Revised Code, the RPH CCO may discharge a patient who is under indictment, sentence of imprisonment, or on probation or parole and who has been AWOL for more than thirty days, but shall give written notice of the discharge to the court having criminal jurisdiction over the patient.

(i) Within ODMH RPHs, this statute is applicable to patients in the following forensic categories: NGRI, IST-U, IST-R, IST-U-CJ, parolee/probationer, jail transfer, capias, and patients on conditional release status.

(ii) The RPH shall also notify the ODMH division of legal and regulatory services and the ODMH office of forensic services of the planned discharge of all patients indicated in this section.

(f) Discharge of civil patients.

The CCO of a RPH may discharge any other (civil) patient who has been AWOL for more than fourteen days.

(g) External AWOL reporting requirements.

The RPH CEO is responsible for additional notification to external agencies in certain cases. For external reporting purposes, the CEO is responsible for developing policies for the timely notification of "critical major" and "major" AWOL incidents to the following agencies:

(i) Ohio state highway patrol and local law enforcement regarding information about individuals that the patient has threatened and RPH think could be in danger;

(ii) County prosecutor and local law enforcement agencies (forensic patients) in accordance with ODMH policy I-12, "Apprehension of Forensic Patients who Leave RPH Grounds";

(iii) Victim or victim representatives in accordance with section 2930.16 of the Revised Code;

(iv) The respective community mental health board; and

(v) Federal authorities (i.e., secret service, the federal marshal's office, etc.) as appropriate.

(h) Quality assurance and quality improvement.

The ODMH division of hospital services will monitor RPH AWOL information (incident reports) and data collection and provide aggregate reports, including analysis of trends, on a quarterly basis.

(7) Other procedures for reporting to central office.

(a) All incidents involving a morbidity, mortality, or sentinel event shall be reviewed and reported to the hospital services morbidity and mortality committee as specified by rule 5122-2-25 of the Administrative Code, "Morbidity, mortality, and sentinel event."

(b) All major incidents as defined in paragraphs (D)(3) and (D)(6) of this rule shall be reported within twenty-four hours of the incident to the division of hospital services using the "Incident Notification Report" form (DMH-ADM-005a); and the "Major Incident Report" form (DMH-7034), with copies going to the following as indicated on DMH-7034.

(i) Deputy director of hospital services;

(ii) ODMH medical director;

(iii) Deputy director of legal and regulatory services;

(iv) Chief of the office of legal services;

(v) Staff counsel in the office of legal services;

(vi) ODMH security consultant;

(vii) Assistant deputy director of hospital services; and

(viii) Clinical safety director of hospital services.

(c) For inpatient programs, all major incidents, including those mentioned in paragraph (D)(6) of this rule, shall be reported to the ODMH office of quality assurance and improvement in central office within twenty-four hours of the incident using the automated PCS incident notification report system, and forms DMH-ADM-005a and DMH-7034.

(d) For CSN programs, all major incidents must be reported to the ODMH office of quality assurance and improvement in central office within twenty-four hours of learning of the incident, using the "CSN Incident Notification Report" form (DMH-CSN-008) and DMH-7034. In addition, the CSN, including its licensed residential facilities, shall report outpatient services incidents in accordance with rule 5122-26-13 of the Administrative Code using "Community Mental Health Agency Notification of Incident" form (DMH-LIC-015c); and report residential facility incidents in accordance with rule 5122-30-16 of the Administrative Code using "Residential Facility Notification of Incident" form (DMH-LIC-015r).

(e) The ODMH office of quality assurance and improvement may require such other reports or documents as are necessary to conclude a review of any incident. Data regarding all incidents shall be maintained in a form specified by central office.

(f) Data regarding minor incidents shall be maintained in a form specified by central office using the automated PCS incident notification report system.

(E) Individual and aggregate analysis.

(1) Each hospital and CSN program shall ensure that all incidents are thoroughly and comprehensively reviewed and analyzed:

(a) At the time of submission, on an individual basis, for adequacy of documentation and necessity for follow-up; and

(b) At regular intervals and yearly, on an aggregate basis, to determine rends or patters indicative of a need for corrective action. Such information shall be made available to the ODMH office of quality assurance and improvement.

(2) At regular intervals, the ODMH office of quality assurance and improvement shall supply RPHs with aggregate data on incidents.

(F) Implementation of incident reporting.

The CEO of each RPH shall be responsible for prescribing guidelines for implementation of this rule.

Replaces: 5122-3-13

Click to view Appendix

Effective: 04/28/2013
Promulgated Under: 111.15
Statutory Authority: 5119.01 , 5119.07 , 5119.43 , 5119.82
Rule Amplifies: 5119.01
Prior Effective Dates: 7/27/1979, 7/1/1980, 2/5/1982, 2/1/2000, 7/15/2000, 9/20/2010