Ohio Administrative Code › Title 5122 - Department of Mental Health and Addiction Services › Chapter 5122-3 - Electroconvulsive Therapy; Incident Reporting; Patient Abuse/Neglect; Etc › Section 5122-3-13 - Regional psychiatric hospital (RPH) incident reporting rule

Current through all regulations passed and filed through July 1, 2024
(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.