Reportable Incidents in Developmental Disability Care
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Reportable Incident Form
Instructions and Definitions
August 2012
9/28/2024
Allegations of:
Abuse: physical, sexual or emotional
Neglect
Exploitation: of money, goods or person
Serious Injury of Unknown Cause
Suspicious Injuries
Death
Incidents of:
Sexual Aggression
Missing Person longer than 15 minutes
Criminal Conduct
Property Destruction greater than $100
Serious Injury to person supported
Serious Injury to another person as a result of a behavioral incident by a person
supported
Reportable Staff Misconduct
Other Types of Incidents (car accidents, house fire, burglary of residence)
Certain types of medication variances (as necessitated by the Medication
Variance Policy and Form)
Specific Behavioral and/or Medical Incidents (with required interventions, see
next slide)
9/28/2024
These incidents are reportable when there is one or more of the following interventions utilized:
Hospital Emergency Room
– also includes an Urgent Care facility when
NOT
used in lieu of a PCP visit.
Psychiatric/Medical Hospitalization
– any hospital admission whether planned or unplanned. Routine,
age related testing is not considered reportable.
Manual or Mechanical Restraints
– these include all behavior related restraints, regardless of length of
time used, type or approved by a plan (all take-downs and prone restraints are prohibited). Restraints
used in the course of medical treatment, positioning or in the prevention of an accident are not
considered behavior related and not considered reportable unless another intervention is utilized.
Protective Equipment
– application of a device to a person’s body part to prevent injury/harm as
related to a behavioral incident. To include helmets, mitts, etc.
Mental Health Mobile Crisis Team
– response by an independent mental health agency team to assess
behavioral/psychiatric crises.
Emergency Psychotropic Medication Administration
– psychotropic medication administration in
response to a specific behavioral event which is
NOT
part of a routine medical order and
NOT
prescribed for a specific medical procedure. This requirement includes PRN medications administered
in response to a behavioral event.
Police
– in person response by law enforcement personnel.
Incarceration
– includes being jailed after an arrest or conviction of a crime.
Abdominal Thrust (Heimlich Maneuver)
– certified staff’s use of an emergency technique to dislodge
food or other object lodged in the windpipe.
911 call
– fire, police or emergency ambulance response.
CPR
– certified staff use of CPR to sustain breathing and heart function.
X-Ray
– use of any imaging technique to determine whether a person supported has a fracture (this
does not include imaging techniques used to diagnose illness).
9/28/2024
9/28/2024
Type the legal last name, first name and
middle initial.
Reportable Incidents apply only to persons
receiving services. Do not enter names of
staff or other persons in this box.
A Reportable Incident Form must be
completed for each person served involved in
an incident.
9/28/2024
Enter the Social Security Number of the
person served. This is to correctly identify
persons who have the same name.
9/28/2024
Enter the MONTH/DAY/YEAR and TIME that the
incident occurred using standard time notation
(AM/PM).
If the incident was not witnessed by anyone,
enter the DATE/TIME the incident was
discovered.
Sometimes it happens that someone witnessed
an incident but it is not reported until later. In
these cases, it is important to enter the
DATE/TIME of when the incident was actually
WITNESSED. The time sequence should be
included in the narrative.
The DATE/TIME at the top of the page should
ALWAYS be earlier than the DATE/TIME the
incident was reported.
9/28/2024
Enter the name of the PROVIDER (agency)
responsible for person served at the time of
the incident.
If the person served was not under the
responsibility of a Provider at the time of the
incident, enter “UNSPECIFIED” in this box.
9/28/2024
Enter the Provider Code in this box. It can be
entered by Incident Management Coordinator
when reviewing the form prior to forwarding
to DIDD.
9/28/2024
If the Provider reporting the incident is
different than the Provider Responsible,
enter that in this box.
9/28/2024
If the incident was witnessed BY ANYONE,
check the appropriate box (staff, person
served or other person)
The person completing the form does not
have to be the person who witnessed the
incident
If the incident was not witnessed by any
person, check the box next to DISCOVERED
(e.g.: discovered injuries)
9/28/2024
Check the most appropriate box to indicate
where the incident occurred
If the incident involved more than one
location, select the location where the
majority of the incident occurred
Discovered incidents will most likely have an
UNKNOWN location but not always
Type the address or location where the
incident occurred or was discovered
9/28/2024
If one of these boxes is checked, this
incident is reportable to DIDD.
More than one box may be checked.
9/28/2024
Summarize the incident in question, being careful to
include pertinent information such as who, what, when
and where. Additionally, include information that was
discovered later such as a medical diagnosis.
Do not use abbreviations, including abbreviations for
medical terms.
If necessary, use this area to discuss a sequence of events,
especially when the time/date of the incident is unknown.
Be cognizant of how the narrative is written. Reportable
Incident Forms are read by a multitude of persons within
DIDD. Errors that should be corrected prior to submission
include spelling errors, punctuation, grammatical errors
and disorganized thought. A RIF is a representation of the
Provider that submits it. Incident Management
Coordinators should not change the content of a RIF but
should review it for accuracy.
Be sure to identify all persons involved, for example, who
is a staff person and who is the person served.
9/28/2024
Give a brief description of the injury
sustained only by the person served.
Include type, size, location and color.
Describe the type and location of treatment.
Do not use abbreviations, including
abbreviations for medical terminology.
If the incident is clearly described within this
section, it is not necessary to forward a copy
of additional records such as medical or
police forms. However, these documents may
be requested by Incident Management or by
an Investigator.
9/28/2024
If a person other than the person served receives
a SERIOUS INJURY as the result of a behavioral
incident by the person served, check the
appropriate box.
SERIOUS INJURY is any injury which required
assessment and treatment
beyond first aid
.
There has to be an assessment as well as
treatment by a medical professional.
Behavioral incidents qualifying for this includes
physical aggression, SIB and/or property
destruction.
The type of injury can be described in the
narrative of the form. This helps determine
whether the incident met the criteria for
reporting to DIDD.
9/28/2024
Document all notifications made with
accurate date/time.
The Chief Officer/AOD section is for
Developmental Centers and private ICF/ID
facilities.
Community Providers will contact the
Regional Office AOD when necessary.
Notification to Adult Protective Services or
Department of Children Services.
Be sure to include the name of the
Investigator contacted when reporting an
allegation of Abuse, Neglect or Exploitation.
9/28/2024
Type the name and title of the person
completing the report.
Enter the date/time the report was
completed. This should not be before or at
the same time the incident occurred.
Incident Management does not require that a
signed copy of the RIF be submitted but the
Provider should maintain a signed copy.
9/28/2024
Provider IMC reviews and corrects any
information necessary on the RIF.
If applicable, the IMC will document any
additional information gathered after the
initial incident was reported.
There is space provided for this information
to be added underneath the section labeled
“Type of Incident”.
9/28/2024
All
BOLDED
types must be reported to DIDD
Investigations within four (4) hours.
Check only the box that best identifies the
type of incident reported.
9/28/2024
Alleged Abuse
– the knowing infliction of injury, unreasonable confinement,
intimidation or punishment with resulting physical harm, pain or mental anguish.
Physical Abuse
Sexual Abuse
Emotional/Psychological Abuse
Alleged Neglect
– Failure to provide goods or services necessary to avoid physical
harm, mental anguish or mental illness, which results in injury or probable risk of
serious harm.
Exploitation
– the deliberate misplacement, misappropriation or wrongful,
temporary or permanent use of belongings or money with or without the person’s
consent. Illegally or improperly using a person or person’s resources for another’s
profit or advantage.
Serious Injury of Unknown Cause
– A serious injury is discovered and cause can not
be determined. A serious injury is an injury that requires assessment and treatment
by a medical professional and includes but is not limited to fractures, dislocations,
concussions, laceration/cut requiring sutures, staples or Dermabond, etc (see
description under “Serious Injury”).
Suspicious Injury
– an injury to a person where abuse or neglect is suspected, or
does not coincide with explanation of how injury was sustained.
Death
– report to Investigations
only if
abuse or neglect is suspected, suspicious or
unexplained.
9/28/2024
Reportable Behavioral/Psychiatric Incident
(subcategories used by DIDD)
Serious Injury to others as a result of
behavioral/psychiatric incident
Property Destruction over $100
Physical Aggression
Self-Injurious Behavior
Suicide Attempt
Swallow Inedible/Harmful Matter
9/28/2024
Sexual Aggression – acts of sexual aggression
by a person served toward any other person.
Missing Person (> 15 minutes) – person served
is missing for longer than 15 minutes unless
the person’s plan specifies there is no risk of
harm to self or others to be unsupervised for
longer than 15 minutes.
9/28/2024
Reportable Medical Incident
(subcategories used by DIDD)
Choking
Fall
Insect/Animal Bite
Reportable Health Issue: Constipation
Reportable Health Issue: Dehydration
Reportable Health Issue: Urinary Tract Infection
Reportable Health Issue: Skin Issue
Reportable Health Issue: Pneumonia
Seizure
Unusual Physical Reaction (allergic reaction)
9/28/2024
Criminal Conduct – Criminal conduct or probable
criminal conduct by a person served.
Other Type of Incident – car accidents, residence
burglarized, house fire.
Reportable Staff Misconduct
(subcategories used by DIDD)
Exploitation under $50
Treatment Plan not Followed
Poor Quality of Supervision
Staff Convenience
Unacceptable Activity
Violation of Rights
Other
9/28/2024
No Apparent Injury – injury is not known at time of
incident or there is no injury after assessment.
Minor Injury – injuries that
do not
require treatment
beyond first aid but are the result of a reportable incident.
Serious Injury – injuries that may be self inflicted or
inflicted by another, accidental or not, known or unknown
cause, and do require assessment and treatment by a
medical professional. Includes but is not limited to:
Fractures
Dislocations
Concussions
Cut/laceration requiring sutures, staples or Dermabond
Torn ligaments
2
nd
and 3
rd
degree burns
Loss of consciousness
Sprain or strain
9/28/2024
Completed and reviewed (by the agency IMC)
RIF should be emailed (or faxed if email
unavailable) to DIDD.Incidentmgmt@tn.gov
(or 1-877-551-5591)
As soon as possible but no later than the next
business day after the incident is reported,
witnessed or discovered. All allegations,
serious injuries of unknown cause, suspicious
injuries and unexplained or suspicious deaths
must be reported to the DIDD Office of
Investigations as soon as possible but no later
than four (4) hours following the discovery of
the incident.
9/28/2024
Be sure to use the most current RIF (July
2013).
There are RIFs for each region. Please make
sure you are using the correct RIF for the
region in which you are reporting the
incident.
Emailed RIFs will receive confirmation of
receipt from DIDD.
RIFs should be typed. Illegible RIFs will be
returned for resubmission.
9/28/2024
The report outlines the criteria for incidents to be classified as reportable in the context of intellectual and developmental disabilities care. It covers various types of incidents, including abuse, neglect, serious injuries, and behavioral or medical incidents requiring specific interventions. The document also details the interventions that necessitate reporting, such as hospitalization, restraints, protective equipment, crisis team responses, and emergency medical procedures. Adherence to these guidelines ensures the safety and well-being of individuals with developmental disabilities.
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Presentation Transcript
DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES Reportable Incident Form Instructions and Definitions August 2012 9/28/2024
WHAT MAKES AN INCIDENT REPORTABLE? Allegations of: Abuse: physical, sexual or emotional Neglect Exploitation: of money, goods or person Serious Injury of Unknown Cause Suspicious Injuries Death Incidents of: Sexual Aggression Missing Person longer than 15 minutes Criminal Conduct Property Destruction greater than $100 Serious Injury to person supported Serious Injury to another person as a result of a behavioral incident by a person supported Reportable Staff Misconduct Other Types of Incidents (car accidents, house fire, burglary of residence) Certain types of medication variances (as necessitated by the Medication Variance Policy and Form) Specific Behavioral and/or Medical Incidents (with required interventions, see next slide) 9/28/2024
REPORTABLE BEHAVIORAL & MEDICAL INCIDENTS These incidents are reportable when there is one or more of the following interventions utilized: Hospital Emergency Room also includes an Urgent Care facility when NOT used in lieu of a PCP visit. Psychiatric/Medical Hospitalization any hospital admission whether planned or unplanned. Routine, age related testing is not considered reportable. Manual or Mechanical Restraints these include all behavior related restraints, regardless of length of time used, type or approved by a plan (all take-downs and prone restraints are prohibited). Restraints used in the course of medical treatment, positioning or in the prevention of an accident are not considered behavior related and not considered reportable unless another intervention is utilized. Protective Equipment application of a device to a person s body part to prevent injury/harm as related to a behavioral incident. To include helmets, mitts, etc. Mental Health Mobile Crisis Team response by an independent mental health agency team to assess behavioral/psychiatric crises. Emergency Psychotropic Medication Administration psychotropic medication administration in response to a specific behavioral event which is NOT part of a routine medical order and NOT prescribed for a specific medical procedure. This requirement includes PRN medications administered in response to a behavioral event. Police in person response by law enforcement personnel. Incarceration includes being jailed after an arrest or conviction of a crime. Abdominal Thrust (Heimlich Maneuver) certified staff s use of an emergency technique to dislodge food or other object lodged in the windpipe. 911 call fire, police or emergency ambulance response. CPR certified staff use of CPR to sustain breathing and heart function. X-Ray use of any imaging technique to determine whether a person supported has a fracture (this does not include imaging techniques used to diagnose illness). 9/28/2024
COMPLETING THE REPORTABLE INCIDENT FORM 9/28/2024
NAME OF PERSON SERVED Type the legal last name, first name and middle initial. Reportable Incidents apply only to persons receiving services. Do not enter names of staff or other persons in this box. A Reportable Incident Form must be completed for each person served involved in an incident. 9/28/2024
SOCIAL SECURITY NUMBER Enter the Social Security Number of the person served. This is to correctly identify persons who have the same name. 9/28/2024
DATE AND TIME OF INCIDENT Enter the MONTH/DAY/YEAR and TIME that the incident occurred using standard time notation (AM/PM). If the incident was not witnessed by anyone, enter the DATE/TIME the incident was discovered. Sometimes it happens that someone witnessed an incident but it is not reported until later. In these cases, it is important to enter the DATE/TIME of when the incident was actually WITNESSED. The time sequence should be included in the narrative. The DATE/TIME at the top of the page should ALWAYS be earlier than the DATE/TIME the incident was reported. 9/28/2024
PROVIDER RESPONSIBLE Enter the name of the PROVIDER (agency) responsible for person served at the time of the incident. If the person served was not under the responsibility of a Provider at the time of the incident, enter UNSPECIFIED in this box. 9/28/2024
PROVIDER CODE Enter the Provider Code in this box. It can be entered by Incident Management Coordinator when reviewing the form prior to forwarding to DIDD. 9/28/2024
PROVIDER REPORTING If the Provider reporting the incident is different than the Provider Responsible, enter that in this box. 9/28/2024
WITNESSED/DISCOVERED If the incident was witnessed BY ANYONE, check the appropriate box (staff, person served or other person) The person completing the form does not have to be the person who witnessed the incident If the incident was not witnessed by any person, check the box next to DISCOVERED (e.g.: discovered injuries) 9/28/2024
WHERE INCIDENT OCCURRED Check the most appropriate box to indicate where the incident occurred If the incident involved more than one location, select the location where the majority of the incident occurred Discovered incidents will most likely have an UNKNOWN location but not always Type the address or location where the incident occurred or was discovered 9/28/2024
THIS INCIDENT REQUIRED If one of these boxes is checked, this incident is reportable to DIDD. More than one box may be checked. 9/28/2024
BRIEF DESCRIPTION OF INCIDENT Summarize the incident in question, being careful to include pertinent information such as who, what, when and where. Additionally, include information that was discovered later such as a medical diagnosis. Do not use abbreviations, including abbreviations for medical terms. If necessary, use this area to discuss a sequence of events, especially when the time/date of the incident is unknown. Be cognizant of how the narrative is written. Reportable Incident Forms are read by a multitude of persons within DIDD. Errors that should be corrected prior to submission include spelling errors, punctuation, grammatical errors and disorganized thought. A RIF is a representation of the Provider that submits it. Incident Management Coordinators should not change the content of a RIF but should review it for accuracy. Be sure to identify all persons involved, for example, who is a staff person and who is the person served. 9/28/2024
DESCRIPTION OF INJURY Give a brief description of the injury sustained only by the person served. Include type, size, location and color. Describe the type and location of treatment. Do not use abbreviations, including abbreviations for medical terminology. If the incident is clearly described within this section, it is not necessary to forward a copy of additional records such as medical or police forms. However, these documents may be requested by Incident Management or by an Investigator. 9/28/2024
INJURY TO OTHERS If a person other than the person served receives a SERIOUS INJURY as the result of a behavioral incident by the person served, check the appropriate box. SERIOUS INJURY is any injury which required assessment and treatment beyond first aid. There has to be an assessment as well as treatment by a medical professional. Behavioral incidents qualifying for this includes physical aggression, SIB and/or property destruction. The type of injury can be described in the narrative of the form. This helps determine whether the incident met the criteria for reporting to DIDD. 9/28/2024
NOTIFIED Document all notifications made with accurate date/time. The Chief Officer/AOD section is for Developmental Centers and private ICF/ID facilities. Community Providers will contact the Regional Office AOD when necessary. Notification to Adult Protective Services or Department of Children Services. Be sure to include the name of the Investigator contacted when reporting an allegation of Abuse, Neglect or Exploitation. 9/28/2024
PERSON WRITING THIS REPORT Type the name and title of the person completing the report. Enter the date/time the report was completed. This should not be before or at the same time the incident occurred. Incident Management does not require that a signed copy of the RIF be submitted but the Provider should maintain a signed copy. 9/28/2024
INCIDENT MANAGEMENT COORDINATOR REVIEW Provider IMC reviews and corrects any information necessary on the RIF. If applicable, the IMC will document any additional information gathered after the initial incident was reported. There is space provided for this information to be added underneath the section labeled Type of Incident . 9/28/2024
TYPE OF INCIDENT All BOLDED types must be reported to DIDD Investigations within four (4) hours. Check only the box that best identifies the type of incident reported. 9/28/2024
TYPES OF INCIDENTS THAT REQUIRE A CALL TO INVESTIGATIONS Alleged Abuse the knowing infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Physical Abuse Sexual Abuse Emotional/Psychological Abuse Alleged Neglect Failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness, which results in injury or probable risk of serious harm. Exploitation the deliberate misplacement, misappropriation or wrongful, temporary or permanent use of belongings or money with or without the person s consent. Illegally or improperly using a person or person s resources for another s profit or advantage. Serious Injury of Unknown Cause A serious injury is discovered and cause can not be determined. A serious injury is an injury that requires assessment and treatment by a medical professional and includes but is not limited to fractures, dislocations, concussions, laceration/cut requiring sutures, staples or Dermabond, etc (see description under Serious Injury ). Suspicious Injury an injury to a person where abuse or neglect is suspected, or does not coincide with explanation of how injury was sustained. Death report to Investigations only if abuse or neglect is suspected, suspicious or unexplained. 9/28/2024
OTHER TYPES OF INCIDENTS THAT ARE REPORTED WITHIN ONE BUSINESS DAY Reportable Behavioral/Psychiatric Incident (subcategories used by DIDD) Serious Injury to others as a result of behavioral/psychiatric incident Property Destruction over $100 Physical Aggression Self-Injurious Behavior Suicide Attempt Swallow Inedible/Harmful Matter 9/28/2024
CONTINUED Sexual Aggression acts of sexual aggression by a person served toward any other person. Missing Person (> 15 minutes) person served is missing for longer than 15 minutes unless the person s plan specifies there is no risk of harm to self or others to be unsupervised for longer than 15 minutes. 9/28/2024
CONTINUED Reportable Medical Incident (subcategories used by DIDD) Choking Fall Insect/Animal Bite Reportable Health Issue: Constipation Reportable Health Issue: Dehydration Reportable Health Issue: Urinary Tract Infection Reportable Health Issue: Skin Issue Reportable Health Issue: Pneumonia Seizure Unusual Physical Reaction (allergic reaction) 9/28/2024
CONTINUED Criminal Conduct Criminal conduct or probable criminal conduct by a person served. Other Type of Incident car accidents, residence burglarized, house fire. Reportable Staff Misconduct (subcategories used by DIDD) Exploitation under $50 Treatment Plan not Followed Poor Quality of Supervision Staff Convenience Unacceptable Activity Violation of Rights Other 9/28/2024
INJURY TYPE No Apparent Injury injury is not known at time of incident or there is no injury after assessment. Minor Injury injuries that do not require treatment beyond first aid but are the result of a reportable incident. Serious Injury injuries that may be self inflicted or inflicted by another, accidental or not, known or unknown cause, and do require assessment and treatment by a medical professional. Includes but is not limited to: Fractures Dislocations Concussions Cut/laceration requiring sutures, staples or Dermabond Torn ligaments 2nd and 3rd degree burns Loss of consciousness Sprain or strain 9/28/2024
FORWARDING RIF TO DIDD Completed and reviewed (by the agency IMC) RIF should be emailed (or faxed if email unavailable) to DIDD.Incidentmgmt@tn.gov (or 1-877-551-5591) As soon as possible but no later than the next business day after the incident is reported, witnessed or discovered. All allegations, serious injuries of unknown cause, suspicious injuries and unexplained or suspicious deaths must be reported to the DIDD Office of Investigations as soon as possible but no later than four (4) hours following the discovery of the incident. 9/28/2024
THINGS TO REMEMBER Be sure to use the most current RIF (July 2013). There are RIFs for each region. Please make sure you are using the correct RIF for the region in which you are reporting the incident. Emailed RIFs will receive confirmation of receipt from DIDD. RIFs should be typed. Illegible RIFs will be returned for resubmission. 9/28/2024
