SECTION 450:17-15-5. Critical incident reporting

(a)   The facility shall have written policies and procedures requiring documentation and reporting of critical incidents and analysis of the contributors to the incident, with attention to issues that may reflect opportunities for system level or program level improvement.

(b)   The documentation for critical incidents shall minimally include:

(1)   the facility, name and signature of the person(s) reporting the incident;

(2)   the name(s) of the consumer(s), staff member(s) or property involved;

(3)   the time, date and physical location of the critical incident;

(4)   the time and date the incident was reported and name of the staff person within the facility to whom it was reported;

(5)   a description of the incident;

(6)   resolution or action taken, date action taken, and signature of appropriate staff; and

(7)   severity of each injury, if applicable. Severity shall be indicated as follows:

(A)   No off-site medical care required or first aid care administered on-site;

(B)   Medical care by a physician or nurse or follow-up attention required; or

(C)   Hospitalization or immediate off-site medical attention was required;

(c)   Critical incidents shall be reported to ODMHSAS with specific timeframes, as follows:

(1)   Critical incidents requiring medical care by a physician or nurse or follow-up attention and incidents requiring hospitalization or immediate off-site medical attention shall be delivered via fax or mail to ODMHSAS Provider Certification within twenty-four (24) hours of the incident being documented.

(2)   Critical incidents involving allegations constituting a sentinel event or consumer abuse shall be reported to ODMHSAS immediately via telephone or fax, but not more than twenty-four (24) hours of the incident. If reported by telephone, the report shall be followed with a written report within twenty-four (24) hours.

(3)   Sentinel events shall have a root cause analysis completed no later than 30 days after the event occurred with a copy of the completed report sent to ODMHSAS.

(d)   Compliance with 450:17-15-5 shall be determined by a review of facility policy and procedures; critical incident reports at the facility and those submitted to ODMHSAS, performance improvement program documents and reports, and staff interviews.

[Source: Added at 14 Ok Reg 1919, eff 5-27-97; Amended at 19 Ok Reg 2333, eff 7-1-02; Amended at 21 Ok Reg 1067, eff 7-1-04; Amended at 22 Ok Reg 960, eff 7-1-05; Amended at 24 Ok Reg 2563, eff 7-12-07; Amended at 27 Ok Reg 2216, eff 7-11-10; Amended at 34 Ok Reg 1777, eff 10-1-17]