HOW TO COMPLETE THE LCBDD UI / MUI Incident Report Form To ensure legibility, please print or type.

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1 HOW TO COMPLETE THE LCBDD UI / MUI Incident Report Form To ensure legibility, please print or type. This form is to be completed by the individual with first knowledge of the incident. FRONT SIDE OF FORM A. CONSUMER IDENTIFICATION BOX: Consumer Name: Print full legal name of consumer. Consumer's Address: This is the legal residential address of the involved consumer. Does individual have a behavior support plan? Indicate whether the consumer has any BSP. It does not matter if the BSP pertains to behaviors occurring in the current incident. SSA Assigned/Name: Indicate whether the consumer is assigned to the caseload of an SSA and the name of the SSA. Individual is Own Guardian: Indicate yes or no. Name of Guardian: Include individual s full name, not only family association, such as mother or sister. B. PROVIDER INFORMATION BOX: Provider of Service: Print the name of the Agency Provider if incident occurs at a provider agency outside of LCBDD or the name of the Individual Provider present at the time of the incident. Provider Contact Person: Name of Provider Agency representative or Individual Provider to contact for further information. Phone Number: This is the contact phone number associated with the listed 'Provider Contact Person'. Date Incident Discovered: This is the date that you became aware of the incident. (Example: Consumer received a black eye on Friday and reported it to OVC staff on Monday. Discovery date would be Monday.) C. INCIDENT INFORMATION: Date Incident Occurred: Print month/date/year that incident occurred. Time of Incident: May use approximate time, or if time of occurrence is unknown, write unknown. Designation of AM or PM is required. Specific Location Where Incident Occurred: This is the exact location, with address if necessary, where incident occurred. D. INCIDENT DESCRIPTION BOX: Explain Incident (who, what, when, where): Describe incident in detail including preceding or contributing events/actions. This should be a factual account of what was seen, heard and done, without emotional content. When possible, use exact quotations of any relevant statements made. (If you heard a consumer swear, state what was heard.) Use full names of all staff and consumers involved, no initials, no agency specific codes/numbers for consumer, nor generic staff or another consumer designation. Write clearly, using exact wording in descriptions. Do not use catch phrases such as assisted to the ground. Instead describe what you physically did to lower the consumer to the floor. If a consumer was struck or hit state whether a closed fist or open hand was used and where on body contact was made. Include as many details as possible within your description of the incident. Page 1 of 5

2 E. WITNESSES: This is a listing of all individuals who were involved in the incident as an Aggressor, Victim or Witness. This includes all consumers, staff or other individuals present at the time of the incident. Name: Print full name of witness. Title: Acceptable completion for Title might be consumer, a job title or vending company employee. Phone #: Phone number where the witness may be contacted for information regarding the incident. F. INJURY INFORMATION BOX: Did Injury Occur: Indicate Yes or No. Assessment Completed by Whom? Print name of individual who completed the medical assessment of the consumer. Title: Print job title or designation associated with the individual completing the medical assessment. Date: This is the date the assessment was completed. Describe the injury/treatment: Identify any observable or known injury and if any treatment was given, such as any tests that were done, splints/braces applied, etc. Was Emergency Transport required to hospital? By whom?: Identify if the consumer needed to be transported to the hospital and if transport was by ambulance (List name of ambulance service, if known) or by an individual. Name of Hospital/ ER Treatment only?/hospital Admittance?: List name of hospital where consumer was taken, indicate if they received emergency room treatment only or if they were admitted to the hospital for further evaluation/treatment. PAGE TWO G. CONSUMER IDENTIFICATION BOX: Consumer Name: Print full legal name of consumer, as printed on first page of form. H. IMMEDIATE ACTION DESCRIPTION BOX: Describe Immediate action taken to ensure health and welfare of the individuals involved: This is a description of the first steps taken to immediately address the situation. For example, if the incident involved a physical confrontation between consumers, the immediate action would begin with separating the consumers. If the report concerns the fall of a consumer, the immediate action would include medically assessing the consumer. I. MEDICAL FOLLOW-UP BOX: Describe any further medical follow-up required: This is a description of any additional follow-up that will be necessary to address the outcome of the incident with any medical professionals. J. SUMMARY OF REPORTING GUIDELINES: REQUIREMENTS FOR MUI REPORTING TO INVESTIGATIVE AGENTS (IAs): This is a reminder that all Alleged Abuse, Neglect, Exploitation, Misappropriation, Suspicious/Accidental Death, or Media Inquiries about an MUI must be verbally reported to an IA within 4 hours of the discovery of the incident. (This includes all peer-to-peer incidents within these categories.) For all categories of MUIs, a written incident report must be received by an IA by 3:00 pm on the next working day following discovery of an incident. (Working day means Monday-Friday except for holidays as defined in Section 1/14 of the Ohio Revised Code.) Page 2 of 5

3 K. REQUIRED NOTIFICATIONS FOR A UI BOX: All reported incidents are initially considered an Unusual Incident. UI and if the incident occurs at a site operated by the county board or at a site operated by an entity with which the county board contracts, the county board or contract entity shall notify the licensed provider or staff, guardian, or other person whom the individual has identified, as applicable, at the individual's resident. This notification must be completed the same day that the Unusual Incident is discovered and documented in this section for each involved and identified consumer. L. REQURIED NOTIFICATIONS FOR A POTENTIAL OR IDENTIFIED MUI: Any potential MUI must be reported to an IA as only an Investigative Agent is authorized to designate an unusual Incident (UI) as a Major Unusual Incident (MUI). All verbal or written contact with an IA to establish MUI status of an incident must be documented as County Board verbal notification and/or County Board written notification and the Name of the IA contacted should be identified. Please note that all Peer-to-Peer incidents are potential MUIs and must be reported to an IA. Guardian/SSA/Residential Provider/Residential Staff-Family/Law Enforcement/Children Services/Support Broker/Other: Once an incident has been identified by an IA as an MUI, appropriate notification and documentation must be completed on the day of occurrence or discovery and include a statement of the immediate action taken. By definition a "Major Unusual Incident" (MUI) means the alleged, suspected, or actual occurrence of an incident when there is reason to believe the health or welfare of an individual may be adversely affected or an individual may be placed at a likely risk of harm, if such individual is receiving services through the DD service delivery system or will be receiving such services as a result of the incident. There are three categories of major unusual incidents that correspond to three administrative investigation procedures delineated in appendix A, appendix B and appendix C of These major unusual incidents (MUIs) include the following: CATEGORY A 1) Abuse: Verbal: The use of words, gestures, or other communicative means to purposefully threaten, coerce, intimidate, harass, or humiliate an individual. Physical: The use of physical force that can reasonably be expected to result in physical harm or serious physical harm. Such force may include, but is not limited to, hitting, slapping, pushing, or throwing objects at an individual. Sexual: Unlawful sexual conduct or sexual contact, as well as, public indecency, importuning, and voyeurism. 2) Neglect: When there is a duty to do so, failing to provide an individual with any treatment, care, goods, supervision or services necessary to maintain the health or welfare of the individual. 3) Exploitation: The unlawful or improper act of using an individual or an individual s resources for monetary or personal benefit, profit, or gain. 4) Misappropriation: Depriving, defrauding or otherwise obtaining the real or personal property of an individual by any means prohibited by the Ohio Revised Code. 5) Peer to Peer Act: One of the following incidents involving two individuals served: Physical Abuse: When an individual is targeting, or firmly fixed on another individual such that the act is not accidental or random and the act results in an injury that is treated by a physician, physician assistant, or nurse practitioner. Allegations of one individual choking another or any head or neck injuries such as a bloody nose, a bloody lip, a black eye, or other injury to the eye, shall be considered major unusual incidents. Minor injuries such as scratches or reddened areas not involving the head or neck shall be considered unusual incidents and shall require immediate action, a review to uncover possible cause/contributing factors, and prevention measures. Verbal Abuse: The use of words, gestures, or other communicative means to purposefully threaten, coerce, or intimidate the other individual when there is the opportunity and ability to carry out the threat. Sexual Abuse: Sexual conduct and/or contact for the purposes of sexual gratification without the consent of the other individual. Page 3 of 5

4 Exploitation: The unlawful or improper act of using an individual or an individual's resources for monetary or personal benefit, profit or gain. Theft: Intentionally depriving another individual of real or personal property valued at $20 or more or property of significant personal value to the individual. 6) Death: Any death of an MR/DD individual. 7) Rights Code Violation: Any violation of an individual s rights (as per ORC ) that creates a likely risk of harm to the health or welfare of an individual. 8) Failure to Report: A person, who is required to report, has reason to believe that an individual has suffered or faces a substantial risk of suffering any wound, injury, disability, or condition of such a nature as to reasonably indicate abuse, misappropriation, or exploitation that results in a risk to health and welfare or neglect of that individual, and that person does not immediately report such information to the appropriate agency. 9) Prohibited Sexual Relations: A DD employee engaging in consensual sexual conduct or having consensual sexual contact with an individual who is not the employee s spouse, and for whom the DD employee was employed, or under contract, to provide care or supervise the provision of care at the time of the incident. CATEGORY B 10) Attempted Suicide: A physical attempt by an individual that results in emergency room treatment, in-patient observation or hospital admission. 11) Medical Emergency: An incident where emergency medical intervention is required to save an individual s life, (e.g., choking relief techniques such as back blows or cardiopulmonary resuscitation (CPR), epinephrine auto injector usage or intravenous for dehydration.) 12) Missing MR/DD individual: An incident that is not considered neglect and the individual's whereabouts, after immediate measures taken, are unknown and the individual is believed to be at or pose an imminent risk of harm to self or others. An incident when an individual's whereabouts are unknown for longer than the period of time specified in the ISP that does not result in imminent risk of harm to self or others shall be investigated as an unusual incident. 13) Significant Injury: An injury of known or unknown cause that is not considered abuse or neglect and that results in concussion, broken bone, dislocation, second or third degree burns or that requires immobilization, casting, or five or more sutures and shall be designated as either known or unknown cause. CATEGORY C 14) Unscheduled Hospitalization: Any hospital admission that is not scheduled unless the hospital admission is due to a pre-existing condition that is specified in the ISP indicating the specific symptoms and criteria that require hospitalization. 15) Law Enforcement: Any incident that results in the individual served being charged, incarcerated, or arrested. 16) Unapproved Behavior Support: The use of an aversive strategy or intervention implemented without approval by the human rights committee or behavior support committee or without informed consent, that results in a likely risk to the individual's health and welfare. M. STAFF COMPLETION SIGNATURE: Staff Signature/Title/Date: The individual completing this form must sign their name, list their title or job position, and identify the date they completed the form. Printed Name: The name of the individual listed above as completing the form must legibly print their name as it is signed in the above line. This form should be completed as soon as possible following the incident. If the incident is believed to be a potential MUI, or involves alleged abuse, neglect, exploitation, misappropriation, suspicious/accidental death, or media inquiries, staff must immediately make verbal contact with a supervisor or IA and follow their direction for completion of the incident report form. Page 4 of 5

5 PAGE THREE N. CONSUMER IDENTIFICATION BOX: Consumer Name: Print full legal name of consumer, as printed on first page of form. UNUSUAL INCIDENT INVESTIGATION SUMMARY REQUIREMENTS FOR UI INVESTIGATION: Revised OAC 5125: states Unusual Incidents shall be reported and investigated by the Provider. This includes identification of the cause and contributing factors when applicable, and the development of preventive measure to protect the health and welfare of any at-risk individuals. Independent providers shall complete an Incident Report, notify the individuals guardian or other person whom the individual has identified and then forward the incident report to the Service and Support Administrator on the same day the Unusual Incident is discovered. NOTE: All potential Major Unusual Incidents must be addressed by the Investigative Agents of the Lorain County Board of Developmental Disabilities - MUI/Investigation Unit. O. Identify the Level of Supervision at time of Incident occurrence as listed in the ISP/IHP: List the specific levels of supervision identified within the consumer's ISP or IHP for all environments with all associated timeframes. P. List all Probable Causes and/or Contributing Factors to the incident: This would include all physical environmental factors and/or any medical/psychological issues of the consumer that may have been present at the time of the incident and provided some impact to the situation. Additionally, personal interactions of the consumer or events prior to the incident should also be identified. Q. Preventative Measures Taken to Protect the Health and Welfare of all at-risk individuals involved in this Incident: This section should address prevention plans that have been implemented for all consumers involved in the incident and should include input from any appropriate team member. R. Documentation Check-off Box: This box should be checked when all documentation necessary to verify that the implementation of the proposed preventative measures has been completed and attached to this UI/MUI Incident Report form. S. SUPERVISORY SIGNATURE: Supervisor Signature/Title/Date: The supervisor completing the Investigation Summary section must sign their name, list their job title or job position, and identify the date they completed this section. Print Name: The name of the supervisor listed above as completing the form must legibly print their name as it is signed in the above line. Page 5 of 5