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| Function: |
Documenting |
| Policy: |
2-100 Incident Reports |
| CMHO Standard(s): |
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| Approved: |
January 2009 |
2-100 INCIDENT REPORTS
Approved January 2009
POLICY
St. Leonard’s Community Services has reporting procedures for documenting incidents related to clients and incidents that are about a program, staff or the community. These incidents are referred to as non-client related incidents.
Incident Reports may be written concerning client related incidents under the following circumstances:
- An increase in the client’s level of risk,
- Threat or risk of harm,
- Program non-compliance.
Client Related Incidents
The following are examples of situations of client related incidents, which require staff to complete an Incident Report:
- Unauthorized absence/missing client,
- Escapes from custody/detention/community residential facility (Peter Willis and Buffalo Street Residence),
- Program Removal/Suspension (Peter Willis and Buffalo Street Residence),
- Client injury (accidental, non accidental), which does not require treatment by a medical practitioner including a nurse or dentist,
- Significant property damage,
- Self harm,
- Physical aggression toward staff,
- Physical aggression toward peer,
- Verbal aggression or threats of violence toward staff,
- Verbal aggression or threats of violence toward peer,
- Victim of verbal or physical assault, i.e. bullying, threats of violence,
- Any use of a physical intervention,
- Disclosure of abuse (also refer to Client Service 10-120 Child Abuse Policy),
- Allegations of abuse made against staff, students, volunteers and temporary care providers (also refer to HR 6-660 Investigation of Complaints Against Staff),
- Sexual behaviour that occurs while participating in an Agency program,
- Police contact/involvement (e.g. Client cautioned/questioned/charged/arrested).
- Possession of contraband (e.g. drugs, alcohol, weapons),
- Substance use/abuse (suspected or confirmed),
- Suicidal ideation,
- Death of a client, (with the exception of Peter Willis Residence)
- Parole/bail/probation violation (Youth and Adult Community Justice Programs, Peter Willis and Buffalo Street Residence),
- Curfew violation (Buffalo Street Residence).
For programs licensed under Child and Family Services Act (CFSA) an incident(s) may be deemed a Serious Occurrence. The decision to deem an incident a Serious Occurrence is made by the staff on duty in consultation with the Manager, On-shift Supervisor or On-Call Supervisor (Refer to Documenting 2-110 Serious Occurrences and 2-90 Log book).
Non-Client Related Incidents
Incident Reports may also be written about situations related to the program, community or staff and are not related to a specific client.
Examples of these types of situations include:
- Missing program keys and/or security equipment (i.e. panic button, walkie talkie),
- Neighbourhood complaints/issues and follow up,
- False fire and panic button alarms,
- Complaints regarding the operational, physical or safety standard of the program,
- Issues with malfunctioning safety/security equipment (e.g. fire panels, panic buttons, etc.),
- Any disaster (e.g. fire) – non-CFSA licensed programs only,
- Police inquiries,
- Damage to Agency vehicle.
PROCEDURE
DOCUMENTING CLIENT RELATED INCIDENTS
A running account of the incident(s) will be recorded in the log book (See Documenting 2-90 Log Book).
Incident Reports (See Documenting Appendix 3 Client Incident Report Form) are completed as soon as possible following the incident by the staff on duty and prior to the completion of the shift/work day. Upon completion, a copy of Buffalo Street Residence Incident Reports are forwarded to the Service Director and Executive Director. For all other Agency programs/services, a notification of the incident report is forwarded to the Service Director.
The incident report will include the following information:
- Client’s Name,
- File Number,
- FPS# (Buffalo Street Residence),
- Date of Birth,
- Date of Incident,
- Time of Incident,
- Location of Incident,
- Serious Occurrence # (if applicable),
- Type of Incident,
- Date Incident Report written,
- Time Incident Report written,
- Name of Staff Making Report,
- Name(s) of Staff on Shift or in the Facility at the Time of Incident,
- Details/Description of Incident (i.e. Who was involved? What happened? When did it happen? Where did the incident occur? What factors contributed to the incident i.e. substance use?
- Details of Client Debriefing,
- Client Debriefing Conducted By,
- Details of Staff Debriefing,
- Staff Debriefing Conducted By,
- Follow-up/Action Plan,
- Who was Notified and When.
Incident Reports are documented and stored on the Client Service Manager database and in the “hard copy” client file.
DOCUMENTING NON-CLIENT RELATED INCIDENTS
A running account of all non-client related incidents will be recorded in the log book (See Documenting 2-90 Log Book).
Incident Reports (See Documenting Appendix 4 Non-Client Related Incident Form) are completed as soon as possible following the incident by the staff on duty and prior to the completion of the shift/work day. Upon completion, the Incident Report is forwarded to the Service Director.
The Incident Report will include the following information:
- Date of Incident,
- Time of Incident,
- Location of Incident,
- Type of Incident (i.e. Incident Report Category),
- Date Incident Report Written,
- Time Incident Report Written,
- Name of Staff Making Report,
- Name(s) of Staff on Shift or in the Facility at the Time of the Incident,
- Details/Description of Incident (i.e. Who was involved? What happened? When did it happen? Where did the incident occur? What factors contributed to the incident?
- Details of Staff Debriefing,
- Staff Debriefing Conducted By,
- Follow-up/Action Plan,
- Who was Notified and When.
The “hard copy” of a Non-Client Related Incident Report will be stored in the Service Director’s or delegate’s office.
ANALYSIS AND REPORTING
Incident Reports are reviewed a minimum of quarterly by each department with a view to prevent future incidents and to assure quality of service. These reviews are documented by Service Directors in staff meeting minutes and/or Case Management Minutes.
Incident Reports for Buffalo Street Residence are included in the Service Director’s Board report, which is reviewed and summarized by the Program Committee for presentation at the next scheduled Board of Directors’ Meeting.
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