SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Columbia, South Carolina

OFFICE OF THE DIRECTOR OF MENTAL HEALTH

DIRECTIVE NO. 897-10

 

(5-100)


TO:                 All Organizational Components

SUBJECT:     Adverse Incident Reporting

I.  PURPOSE
This directive establishes the Department of Mental Health's policy and procedure for reporting adverse incidents involving the Department's Inpatient Facilities, Community Mental Health Centers and Programs.

II. POLICY
In the interest of improving the quality of care provided by the Department of Mental Health (DMH) and ensuring the safety of DMH clients, staff and visitors, it is the policy of the Department of Mental Health to continuously and systematically monitor and evaluate all Adverse Incidents. An Adverse Incident is any situation in which the health, safety or welfare of DMH clients, staff and visitors has been adversely affected.

The reporting of adverse incidents pursuant to this Directive is part of the DMH process to ensure quality services, improve treatment programming and, as outlined by the Directive entitled “Quality of Care Review Boards and Case Reviews,” perform self-critical analyses.  Reports are therefore not only confidential, but legally privileged

III. RESPONSIBILITIES

  1. It is the responsibility of the Director of each inpatient facility, community mental health center, and program to promptly, accurately and adequately report adverse incidents to DMH as described in this directive. The Director shall also institute any necessary corrective action and verify the implementation of that corrective action.
  2. The Office of Risk Management (ORM) is responsible for receiving, monitoring and evaluating Adverse Incident Reports as described in this directive. As necessary, ORM shall keep the appropriate members of DMH Management responsible for the agency's clinical policies and procedures, quality assurance, performance improvement and risk management informed, and may recommend additional corrective action.
  3. ORM shall monitor adverse events over time to identify discernible trends which may warrant further systematic review. ORM will present trend data and recommendations to the General Counsel and Medical Director.

IV. DEFINITIONS

  1. A “client” is an individual who is on an inpatient facility's census or presently is, or (within the past six months) has had, an open case at a community mental health center.
  2. A “death” includes a death by suicide.
  3. Facility” refers to any inpatient hospital or treatment facility, skilled nursing facility, or infirmary whether operated or contracted for by DMH.
  4. CMHC” refers to any Community Mental Health Center outpatient treatment program operated by or contracted for by DMH, including CRCFs or other residential programs.
  5. DMH staff” refers to professional clinical staff (Doctors, Nurses, Counselors, Social Workers, Case Managers) who work the South Carolina Department of Mental Health, including contracted clinical staff.
  6. A “serious injury” is one which results in a bone fracture, lacerations requiring three or more sutures, x-rays or electronic scans that confirm or do not rule out internal injury, or physical consequences of events requiring medical attention beyond standard first-aid.
  7. An “Adverse Incident” includes the following:
    1. Deaths (includes Suicides) in the following categories:
      a. Any inpatient facility client whose death involves unusual circumstances or is unexpected and not of natural causes. In these cases, all reasonable efforts should be made by the Facility to obtain the Autopsy and/or Coroner’s report.

      b. Any CMHC client whose death occurs:
           1. On CMHC premises,
           2. During a CMHC supervised activity or
           3. Not of natural causes, of currently unknown causes, or involves unusual circumstances. In these      cases, all reasonable efforts should be made by the Center to obtain an Autopsy and/or Coroner’s      report.

      c. Any non-DMH client who is seen by DMH staff for the purposes of assessing mental health status and who completes suicide within seven days of the screening.

      This includes persons assessed in jails, hospitals and Centers who are not formal clients of DMH.

    2. Suicide Attempt:
      a.   By any facility client,
      b.   By any CMHC client that results in serious injury or
      c.   By any CMHC client on the grounds of a CMHC

    3. Homicide or Attempted Homicide by client or by a non-DMH client who is seen by DMH staff for the purposes of assessing mental health status and who commits or attempts homicide within seven days of the screening.

      This includes persons assessed in jails, hospitals and Centers who are not formal clients of DMH.

    4. Sexual Assault occurring
      In a DMH facility,
      On CMHC premises,
      By a DMH client or
      To a DMH client residing in a CRCF or DMH sponsored housing arrangement
      (Sexual conduct between clients under the age of 16, even if apparently "consensual,” shall be considered a reportable event for purposes of this Directive.)

    5. Elopement of Client.  Any unauthorized absence:
      a.  Of a forensic patient from a DMH Facility or a resident of the DMH Sexually Violent Predator Program of greater than one (1) hour.
      b.  From DMH inpatient facility for more than eight (8) hours or resulting in adverse outcome.

    6. Medication Related Serious Adverse Events at DMH facility or CMHC resulting in serious adverse reaction.

    7. Medical Emergencies of significance, to include heart attacks, strokes, seizures, and choking events.

    8. Serious Injuries to staff, client or visitor:
      On premises of DMH facility, CMHC, or CMHC program
      During a DMH supervised activity
      While being transported in a DMH vehicle
      Serious self-inflicted injury by client

    9. Allegations of Physical Abuse, Sexual Abuse, Psychological Abuse, Neglect or Exploitation of Clients against DMH staff.

    10. Serious Act of Violence by or against MHC client

    11. Significant event involving external to DMH law enforcement or report by media.

    12. Other incidents or unusual situations at Center or Facility Director’s discretion.

V.   PROCEDURE

  1. Telephonic reporting is required for the following Adverse Incidents:  suicides, homicides, sexual assaults in a DMH facility or on CMHC premises and elopements of forensic patients from a DMH facility or a resident of the DMH SVP of greater than one (1) hour. All other adverse incidents listed above can be reported telephonically at the discretion of the Facility/Center Director

    The purpose of immediate notification is to inform DMH management of major events which may require a response beyond the capability of the Facility, Center or Program, or which may result in public or news media attention. The Facility, Center or Program Director will pre-designate staff to be responsible for ensuring Adverse Incidents are reported in accordance with this paragraph.

    Immediate notification of the above referenced adverse incidents will be made to:
          (a) The Director of Community Mental Health Services or the Director of Inpatient  
                Services, as appropriate, or their designee, who will ensure that the State Director,
                Medical Director, and Office of Public Affairs are briefed, as appropriate.
          (b)  The Office of Risk Management who will brief General Counsel.
          (c)  The Director of the Division of Public Safety.

  2. Form C174, "Red Stripe Report", signed by the Facility, Center or Program Director, will be submitted to the Office of Risk Management within 2 business days of any incident described in categories 1-12 above. If Center/Facility is procuring additional information to supplement Adverse Incident Report, the report should not be held; send additional information as an addendum when it becomes available.

    Any emails pertaining to adverse events must:
    1)   Avoid identifiers (client name, CID, DOB, etc) in the subject line,
    2)   Be limited to Office of Risk Management and Risk Management point of contact at  
          Center/Facility,
    3)   Be encrypted if it leaves internal DMH email system and
    4)   Contain the following paragraph:

    PRIVACY NOTICE:  THIS COMMUNICATION IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT IS ADDRESSED AND MAY CONTAIN SCDMH PATIENT OR OTHER INFORMATION, THAT IS PRIVATE AND PROTECTED FROM DISCLOSURE BY APPLICABLE FEDERAL AND/OR STATE LAW.  IF THE READER OF THIS MESSAGE IS NOT THE INTENDED RECIPIENT OR RESPONSIBLE FOR DELIVERING THE MESSAGE TO THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION OR THE INFORMATION CONTAINED WITHIN IT, IS STRICTLY PROHIBITED AND MAY SUBJECT THE VIOLATOR TO CIVIL AND/OR CRIMINAL PENALTIES.  IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY US IMMEDIATELY BY TELEPHONE, REPLY E-MAIL OR FAX USING THE PHONE NUMBER OR ADDRESS  IDENTIFIED IN THIS COMMUNICATION  AND DESTROY OR DELETE ALL COPIES OF THIS COMMUNICATION AND ALL ATTACHMENTS.

  3. Reporting Adverse Incidents under this directive is in addition to, and not a substitute for, the reporting required by other laws, regulations, or agency Directives. Allegations of patient abuse age 18 and older must be reported immediately to SLED and the Office of Public Safety; allegations of patient abuse under age 18 must be reported immediately to the Office of Public Safety (reference SCDMH Directive 885-07, “Abuse, Neglect or Exploitation of Patients and Clients Prohibited; and SCDMH Directive 789-94, “Criminal Sexual Assault”).

This directive rescinds and replaces Directive No. 831-02, "Reporting Adverse Incidents", dated July 29, 2002.


John Connery's signature

John H. Magill, State Director   

 

March 30, 2010