Agency Incident Report

  • ARC HUMAN SERVICES INCIDENT REPORT

  • Date Of Report*
     - -
  • Date and Time of Incident*
     - -
     :
  • Did the incident involve Seizures, Dehydration, Constipation, Choking, or Falling?*
  • Please select all that apply.*

  • SEIZURES

    Mild Symptoms                                               Intense Symptoms
    Staring                                                           Loss of consciousness
    Unresponsive                                            Brief muscle jerks and spasms
    Confused                                                      Loss of bladder or bowel
    Twitching of face                                              Limp/collapse on floor
    Lip smacking                                              Rigid muscle tone and jerking
    Numbness/tingling in body                          Change in breathing pattern

    What to Do During a Seizure

    Ensure safe surroundings                                                                                                    Provide padding under person’s head                                                                              Loosen clothing, jewelry around neck                                                                           Stay with person
    Remove glasses                                                                                                             Check for breathing throughout seizure
    Turn person on side

     

    Do Not!
     Do not put anything in mouth (cannot swallow tongue!)
     Do not restrain or hold the person down (cannot stop a seizure!)
     Do not give anything to eat or drink until fully awake (person may choke/ aspirate!)
     Do not attempt artificial respiration unless not breathing


    Call 911 if:

     It is the person’s first seizure
     The person is not breathing
     The seizure lasts over 5 minutes
     Seizures continue one after another without the person regaining consciousness
     Head or other bodily injury occurred during seizure
     Seizure occurs in the water
    Follow your agency policies.

  • DEHYDRATION


    Causes of Dehydration

    Diarrhea and vomiting
    Sweating excessively
    Fever
    Medication side effects

    Medical conditions – diabetes undiagnosed or
    uncontrolled, kidney disease, Crohn’s disease
    Inability to communication thirst
    Reliance on caregivers to provide fluids
    Aging changes that lead to dehydration

    Signs of Dehydration

    Dry mouth                                        Weak
    Headache                                        Thirsty
    Dizzy/lightheaded                    Decrease in urination
    Sleepy/difficult to arouse        Dark concentrated urine

  • Constipation

    Causes of Constipation

    Lack of fiber                                    Associated with medical conditions diabetes
    Inadequate fluids                               Stroke, cerebral palsy, Down syndrome
    Lack of exercise                                  Not enough time to use the toilet
    Side effects of medications

     

    Symptoms of Constipation

    Small, hard stools                                         Refusing to participate in activities
    Crying, grimacing, grunting, straining on toilet           Lack of appetite                              Rectal digging                                       Avoids using the bathroom due to pain
    Hitting abdomen                                   Staying in the bathroom for long periods
    Hard, protruding abdomen                                               Fever

  • CHOKING/ASPIRATION - CALL 911


    Causes of Choking

    Poor Eating Habits                                  Medical Reasons for Choking
    Eating too fast                                                                                 Dry mouth
    Placing large amounts of food in mouth                                     Decayed /missing teeth
    Choosing not to wear dentures                                              Difficulty chewing/swallowing
    Poor posture                                                                                      Aging
    Eating food different from consistency of one’s food                  Certain medications
                                                                                                             GERD

    Signs of Choking

    Severe coughing, gagging                            Anxious/agitated
    Hitting chest                                                     Red face
    Putting hands on throat                                Noisy breathing
    Unable to talk                                  Skin color change – gray or blue
    Unable to breath                                       Loss of consciousness

    ONE SINGLE CHOKING EVENT MAY BE A WARNING SIGN FOR FUTURE CHOKING EVENTS.

  • Did the incident involve any form of a restraint?*
  • Please select level of PEI utilized.*
  • PEI Level 1*
  • PEI Level 2*
  • Did the restraint last longer than 30 minutes within a 2 hour time frame?*
  • Was First Aid Administered or body check completed?*
  • Was there any treatment provided by a medical provider? i.e. Emergency Room, Doctors, Station MD, Urgent Care, PCP*
  • Did this incident involve a medication error?*
  • Date and time of discovery
     - -
     :
  • Error due to*

  • What type of medication error was it? (select all that apply)*
  • Staff position of the person giving medication*

  • Did the error occur over multiple consecutive administrations?*
  • Did the error occur due to a failure to implement medication changes in a timely manner?*

  • Due to answers selected, this incident is now considered neglect and a report needs filed as such.

  • Why did the error occur? (select all that apply)*

  • What was the response to the error? (select all that apply)*

  • Clear
  • This next section is to be completed by a Program Specialist or Director. Are you that person?*
  • What was or will be the agency system response to prevent this type of error from occurring in the future? (Med Error)

  • Was the staff involved working longer than their regular work hours at the time of the error? (Med Error)
  • Were any medications involved in this medication error a controlled substance?
  • Was parent, guardian, residential provider, SC or BCM notified?*
  • Who was notified?*

  • Date notified*
     - -
  • How were they notified?*

  • Were supports offered to the individual/victim?*
  • What supports were offered to the individual/victim? (Medical Attention)*

  • Other Supports*

  • Was a call made to 911?*

  • Program Manager/Supervisor or Program Director to contact if any of the following apply:

    *Additional Notification Required if Abuse, Neglect, Exploitation, or Abandonment:

    Under 18

    1) In addition to ensuring the health and safety and following agency protocol, a report MUSTBE made to Childline at #1-800-932-0313 or https://www.compass.state.pa.us/cwis/public/home

    Age 18-59

    1) An oral report should be made by calling the statewide Protective Services Hotline #1-800490-8505

    2) If suspected abuse or neglect involves sexual abuse, serious injury, serious bodily injury, or a suspicious death then one must also contact PA DHS/APS Division at (717) 265-7887 AND local law enforcement

    3) Within 48 hours of making the oral report to the hotline, a written report must be faxed to #484-434-1590 or emailed to Liberty Healthcare at mandatoryron@libertyhealth.com.  (The report should be a printout of the EIM print summary)

    *Refer to the matrix for additional reporting requirements if law enforcement is involved or serious bodily injury has occurred*

    Protective Services Hotline - 1-800-490-8505

  • OAPSA (Over 60) Oral Report to Local Area Agency on Aging (AAA) Office*
  • APS (18-59)*
  • Has an EIM report been completed for this incident?*
  • What date was the EIM report entered?*
     - -
  • The above information is complete and accurate to the best of my knowledge.
  •  :
  • Should be Empty: