Free 53808.pdf - Indiana

Residential/Hospital/Sentinel Event/Assertive Community Treatment (ACT) Incident Report
State Form 53808 (12-08) / DMHA 1011

Instructions:

Follow instructions on page 3. Fax form to 317-233-1986.

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Indiana Family and Social Service Administration Division of Mental Health and Addiction 402 West Washington Street W353 Indianapolis, IN 46204 Fax: 317-233-1986

Legal Name of Agency:

Name of Residence:

Location/Address of Incident: (number and street, city, state, ZIP code) Person Completing Form: Telephone Number: ( )

Type of Report: Check all that apply. More than one type may apply to some incidents. Complete the corresponding matrix below. Residential Setting Sentinel Event ACT Hospital/Private Mental Health Institution
Residential Setting: A report is required within 24 hours of incident. TRS Transitional Residential AFA Alternative Family for Adults SGL Supervised Group Living SILP Semi Independent Living Sub Acute Sub Acute Stabilization Agency Apt. Agency owned bldg/structure Sentinel Event: A serious and undesirable occurrence involving the loss of life, limb, or function that occurs on the property of the HAP Provider Organization or its subcontractors. A report is required within 24 hours of incident. Assertive Community Treatment (ACT) : A report is required within 24 hours of incident. Hospital/Private Mental Health Institutions: Incidents involving items 1-5, a verbal report is required within 24 hours and a written report within ten (10) days. Incidents involving items 6-11, a report is required within ten (10) working days.

Residential Setting:
(check only one box)

SETTING AND TYPE OF INCIDENT Residential Incident: 440 IAC 7.5
(check all that apply)

Sentinel Event:
(check only one box)

1. TRS 2. SILP 3. AFA 4. Sub Acute 5. SGL 6. Agency Apt 7. Other (specify): a. School b. Nursing Home c. Other (specify):

1. Fire 2. Res temp/perm uninhabitable 3. Injury 4. Suicide attempt 5. Emergency room visit 6. Elopement 7. Police response 8. Alleged exploit., abuse, neglect 9. Suicide 10. Death 11. Other: (specify):

1. Loss of Life 2. Loss of Limb 3. Loss of Function 4. Other: (specify) A.C.T.: 440 IAC 5.2
(check all that apply)

1. Suicide/Suicide attempt 2. Death of consumer 3. Documented violation of rights 4. Other: (specify):

Hospital/Private Mental Health Institution: 440 IAC 1.5 (check all that apply) 1. Death not related to seclusion or restraints. 2. Death while consumer was in restraint or seclusion; within 24 hours after being removed from restraint or seclusion; within one (1) week after restraint or seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to that consumer's death ("reasonable to assume" includes, but is not limited to, deaths related to: (A) restrictions of movement for prolonged periods of time; (B) chest compression; (C) restriction of breathing; or (D) asphyxiation). 3. A serious, unexpected consumer injury resulting in or potentially resulting in loss of function and/or marked deterioration in a consumer's condition 4. Chemical poisoning resulting in actual or potential harm to the consumer 5. Disruption of service exceeding four (4) hours caused by internal disasters, external disasters, strikes by health care workers, or unscheduled revocation of vital services. 6. Consumer missing more than 24 hours 10. Unexplained loss or theft of controlled substance 7. Kidnapping of consumer 11. Fire/Explosion with emergency response 8. Admission of child (14 & under) to adult unit. 12. Other: (specify) 9. Documented violation of rights

Consumer or Alleged Victim Name: Alleged Perpetrator Name:

Sex:

male female male female

Age:

1. Consumer 2. AF/ Householder 3. Staff/Volunteer 1. Consumer 2. AF/ Householder 3. Staff/Volunteer

4. Other (specify):

Sex:

Age:

4. Other (specify):

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Date of incident: (mm/dd/yyyy)

Notification made to: Adult Protective Services (APS) Child Protective Services (CPS) yes no n/a yes no n/a Description of Incident:

If yes, indicate the date notified: (mm/dd/yyyy)

Incident Resolution/Agency's Plan of Action:

Person Submitting Incident Report: DMHA Only (Incident Follow Up As Applicable):

Date: (mm/dd/yyyy)

Liaison's Initials: DMHA only Agency Number:

Date follow up completed: (mm/dd/yyyy)

Date DMHA Received Report: (mm/dd/yyyy) Agency Submitted Report Timely: Page 2 of 3 yes no

Forward to Liaison:

yes

no

Definitions and Instructions for State Form 53808, Residential/Hospital/Sentinel Event/ACT Incident Report
Identifying Information Legal Name of Agency: Name under which the agency has been certified. Name of Residence: Name of the setting where the consumer(s) involved in the incident resides. Location Address of Incident: Address and/or location where the incident occurred. Person Completing Form: Name of the person filling out the Residential/Hospital/Sentinel Event/ACT Report form. Telephone: Telephone number, with area code, where the person who filled out the Residential/Hospital/Sentinel Event/ACT Report form can be reached. Type of Report: Check any report type that applies. For certain incidents, more than one report type may apply. After you have checked the appropriate report type(s), please go to the corresponding matrix below. Setting and Type of Incident Check only one box in this matrix. The selection should be based on the type of residential setting Residential in which the consumer(s) involved in the incident resides. If the type of residential setting is not Incident Setting represented on the form, please check the Other box and specify the residential setting. Check any box in this matrix that applies. If the type of incident that occurred is not represented, Residential please check the Other box and specify the type of incident that occurred. Incident Check only one box in this matrix. This selection should be based on the type of incident consumer(s) are involved in (i.e. loss of life, limb, or function). If the type of incident that occurred Sentinel is not represented, please check the Other box and specify the type of incident that occurred. Check any box in this matrix that applies. If the type of incident that occurred is not represented, ACT please check the Other box and specify the type of incident that occurred. Check any box in this matrix that applies. If the type of incident that occurred is not represented, Hospital please check the Other box and specify the type of incident that occurred. Resident or Alleged Victim(Alleged Perpetrator, if applicable) Name: Name of the consumer or name of the alleged victim involved in the incident. If applicable, name of the alleged perpetrator. Sex: Check the box that applies to the gender of the person named. Age: Indicate the Age of the person named. Category: Check only one box in this matrix. The selection should be based on the category to which the consumer or victim belongs. If the category to which the consumer or victim belongs is not represented, please check the Other box and specify the consumer or victim's category. Date of Incident: Date the incident took place. Notification Made To: Check the box in the Adult Protective Services (APS) section that applies. Check the box in the Child Protective Services (CPS) section that applies. Date Notified: If either APS or CPS were contacted, write the date that contact occurred. If neither APS nor CPS were contacted, leave this space blank. Write a detailed description of the incident that took place. Description of Incident Incident Resolution/Agency's Plan of Action Write a detailed description of how the incident has been resolved and or the agency's plan of action to resolve the incident and if applicable efforts to reduce future occurrences of such incidents. Name of the person who is submitting the report to DMHA. Person Submitting Report Date the form is completed. Date DMHA Only The information in this section is to be completed by DMHA staff only.

Procedure: Complete the Residential/Hospital/Sentinel Event/ACT Incident Report form and fax to DMHA.

DMHA FAX Number: 317-233-1986
Please remember to fax both pages of the completed form.

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