DMHDDAS Incident Report and Peer to Peer with No or Minor Injury ...
DMHDDAS Incident Report and Peer to Peer with No or Minor Injury ...
DMHDDAS Incident Report and Peer to Peer with No or Minor Injury ...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
Individual Name: Rec<strong>or</strong>d Individual’s name <strong>Incident</strong> # Rec<strong>or</strong>d <strong>Incident</strong> #<strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation ReviewAudit Tool InstructionsDate of <strong>Incident</strong> Date of Review Reviewer Investiga<strong>to</strong>r/ Team LeaderRec<strong>or</strong>d the date ofthe incidentRec<strong>or</strong>d the date ofthe ReviewRec<strong>or</strong>d theReviewer’s nameInv: Rec<strong>or</strong>d theinvestiga<strong>to</strong>r’s nameTL: Rec<strong>or</strong>d the TeamLeader’s nameFacilityRec<strong>or</strong>d the name ofthe facilityInstructions: All inf<strong>or</strong>mation <strong>to</strong> complete the <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> Investigation Review is obtained from the <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong><strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review. All St<strong>and</strong>ards should be marked as follows:Individual A = Aggress<strong>or</strong>, throughout the f<strong>or</strong>m Individual B = Victim, throughout the f<strong>or</strong>mF<strong>or</strong> further inf<strong>or</strong>mation related <strong>to</strong> the St<strong>and</strong>ards, see the <strong>DMHDDAS</strong> Facility Risk Management Pro<strong>to</strong>col (FRMP) effective<strong>No</strong>vember 1, 2008.St<strong>and</strong>ard f<strong>or</strong> Facility Responsibility<strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong>1. All applicable areas on Page 1 of the<strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> are completedc<strong>or</strong>rectly.2. All applicable areas on Page 2 of the<strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> are completedc<strong>or</strong>rectly.3. All applicable areas on Page 3 of the<strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> are completedc<strong>or</strong>rectly.4. All applicable areas on Page 5 of the<strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> are completedc<strong>or</strong>rectly.St<strong>and</strong>ard f<strong>or</strong> Facility Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> Aggression <strong>with</strong> <strong>No</strong> <strong>or</strong>Min<strong>or</strong> <strong>Injury</strong> Investigation5. All applicable areas on Page 1 of the<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>Investigation <strong>Rep<strong>or</strong>t</strong> are completedc<strong>or</strong>rectly.Yes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.This st<strong>and</strong>ard is YES if:a. All applicable areas on Page 1 are completed c<strong>or</strong>rectly.This st<strong>and</strong>ard is NO if:a. Any applicable area on Page 1 that should have beencompleted is blank <strong>or</strong> completed inc<strong>or</strong>rectly.This st<strong>and</strong>ard is YES if:a. All areas on Page 2 are completed c<strong>or</strong>rectly.This st<strong>and</strong>ard is NO if:a. Any applicable area on Page 2 that should have beencompleted is blank <strong>or</strong> completed inc<strong>or</strong>rectly.This st<strong>and</strong>ard is YES if:a. All applicable areas on Page 3 are completed c<strong>or</strong>rectly.This st<strong>and</strong>ard is NO if:a. Any applicable area on Page 3 that should have beencompleted is blank <strong>or</strong> completed inc<strong>or</strong>rectly.This st<strong>and</strong>ard is YES if:a. All applicable areas on Page 5 are completed c<strong>or</strong>rectly.This st<strong>and</strong>ard is NO if:a. Any applicable area on Page 5 that should have beencompleted is blank <strong>or</strong> completed inc<strong>or</strong>rectly.CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.This st<strong>and</strong>ard is YES if:a. All applicable areas on Page 1 are completed c<strong>or</strong>rectly.This st<strong>and</strong>ard is NO if:a. Any applicable area on Page 1 that should have been<strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 1 of 10
St<strong>and</strong>ard f<strong>or</strong> Facility Responsibility<strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong>6. All applicable areas on Page 2 of the<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>Investigation <strong>Rep<strong>or</strong>t</strong> are completedc<strong>or</strong>rectly.7. All applicable areas on Page 3 of the<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>Investigation <strong>Rep<strong>or</strong>t</strong> are completedc<strong>or</strong>rectly.Yes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.completed is blank <strong>or</strong> completed inc<strong>or</strong>rectly.This st<strong>and</strong>ard is YES if:a. All applicable areas on Page 2 are completed c<strong>or</strong>rectly.This st<strong>and</strong>ard is NO if:a. Any applicable area on Page 2 that should have beencompleted is blank <strong>or</strong> completed inc<strong>or</strong>rectly.This st<strong>and</strong>ard is YES if:a. All applicable areas on Page 3 are completed c<strong>or</strong>rectly.This st<strong>and</strong>ard is NO if:a. Any applicable area on Page 3 that should have beencompleted is blank <strong>or</strong> completed inc<strong>or</strong>rectly.St<strong>and</strong>ard f<strong>or</strong> Supervis<strong>or</strong> Responsibility:Any “blank” blocks (having zero inf<strong>or</strong>mation <strong>or</strong> “NA”) in the Investigation should be marked as ”NO,does not meet the st<strong>and</strong>ard” in this audit <strong>to</strong>ol.St<strong>and</strong>ard f<strong>or</strong> Supervis<strong>or</strong> Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>Investigation1. Immediate steps <strong>to</strong> SECURE THESCENE are rec<strong>or</strong>ded.Yes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.This st<strong>and</strong>ard is YES if, where applicable, the followingitems are rec<strong>or</strong>ded:a. First aid <strong>or</strong> medical care has been provided <strong>or</strong> obtained(may be found here <strong>and</strong>/<strong>or</strong> on Page 3 of the <strong>Incident</strong><strong>Rep<strong>or</strong>t</strong> under Medical Assessment); <strong>and</strong>b. Interventions were put in place <strong>to</strong> ensure the safety ofall individuals, staff, <strong>and</strong> other persons, e.g. separationof peers involved <strong>and</strong>/<strong>or</strong> other peers as applicable, <strong>and</strong>c. Pho<strong>to</strong>graphs were obtained of all visible injuries <strong>or</strong>pho<strong>to</strong>graphs <strong>to</strong> document that no injury is present; <strong>and</strong>d. Persons were prohibited from removing <strong>or</strong> destroyingpotential <strong>or</strong> actual evidence; <strong>and</strong>e. Potential witnesses were kept at the scene, <strong>and</strong>i. Kept separated when possible, while ensuringadequate supervision of all individuals;ii. If separation was not possible, assigned <strong>or</strong> requestedan additional supervis<strong>or</strong> <strong>to</strong> the scene <strong>to</strong> minimize thepotential witnesses from discussing the incidentamong themselves;iii. Separated as soon as replacement staff coverage isassigned <strong>and</strong> present, ORf. A clear reason f<strong>or</strong> not doing elements a-e as applicableare rec<strong>or</strong>ded.This st<strong>and</strong>ard is NO if, as applicable:<strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 2 of 10
St<strong>and</strong>ard f<strong>or</strong> Supervis<strong>or</strong> Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>Investigation2. Activity of the individuals bef<strong>or</strong>e theincident is rec<strong>or</strong>ded.2. Individual A (Aggress<strong>or</strong>)a.Yes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.a. Elements described in a-e above are not rec<strong>or</strong>ded, <strong>or</strong>b. A clear reason f<strong>or</strong> not doing elements a-e is notdocumented.This st<strong>and</strong>ard is YES if:a. Activity of Individual A bef<strong>or</strong>e the incident is rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Ais present.2.b.Individual B (Victim)This st<strong>and</strong>ard is NO if:a. Activity of Individual A bef<strong>or</strong>e the incident is notrec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Ais not present.This st<strong>and</strong>ard is YES if:a. Activity of Individual B bef<strong>or</strong>e the incident is rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Bis present.3. Activity of the staff bef<strong>or</strong>e theincident is rec<strong>or</strong>ded.3.a.Staff A (Staff assigned <strong>to</strong> theindividual who is the aggress<strong>or</strong>)This st<strong>and</strong>ard is NO if:a. Activity of Individual B bef<strong>or</strong>e the incident is notrec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Bis not present.This st<strong>and</strong>ard is YES if:a. Activity of Staff A bef<strong>or</strong>e the incident is rec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff A ispresent.3.b.Staff B (Staff assigned <strong>to</strong> theindividual who is the Victim)This st<strong>and</strong>ard is NO if:a. Activity of Staff A bef<strong>or</strong>e the incident is not rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff A isnot present.This st<strong>and</strong>ard is YES if:a. Activity of Staff B bef<strong>or</strong>e the incident is rec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff B ispresent.This st<strong>and</strong>ard is NO if:a. Activity of Staff B bef<strong>or</strong>e the incident is not rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff B is<strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 3 of 10
St<strong>and</strong>ard f<strong>or</strong> Supervis<strong>or</strong> Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>Investigation4. Activity of the individuals during theincident is rec<strong>or</strong>ded.4. Individual A (Aggress<strong>or</strong>)a.Yes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.not present.This st<strong>and</strong>ard is YES if:a. Activity of Individual A during the incident is rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Ais present.4.b.Individual B (Victim)This st<strong>and</strong>ard is NO if:a. Activity of Individual A during the incident is notrec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Ais not present.This st<strong>and</strong>ard is YES if:a. Activity of Individual B during the incident is rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Bis present.5. Activity of the staff during theincident is rec<strong>or</strong>ded.5.a.Staff A (Staff assigned <strong>to</strong> theindividual who is the aggress<strong>or</strong>)This st<strong>and</strong>ard is NO if:a. Activity of Individual B during the incident is notrec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Bis not present.This st<strong>and</strong>ard is YES if:a. Activity of Staff A during the incident is rec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff A ispresent.5.b.Staff B (Staff assigned <strong>to</strong> theindividual who is the Victim)This st<strong>and</strong>ard is NO if:a. Activity of Staff A during the incident is not rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff A isnot present.This st<strong>and</strong>ard is YES if:a. Activity of Staff B during the incident is rec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff B ispresent.6. Activity of the individuals after theThis st<strong>and</strong>ard is NO if:a. Activity of Staff B during the incident is not rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff B isnot present.<strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 4 of 10
St<strong>and</strong>ard f<strong>or</strong> Supervis<strong>or</strong> Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>Investigationincident is rec<strong>or</strong>ded.6. Individual A (Aggress<strong>or</strong>)a.Yes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.This st<strong>and</strong>ard is YES if:a. Activity of Individual A after the incident is rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Ais present.6.b.Individual B (Victim)This st<strong>and</strong>ard is NO if:a. Activity of Individual A after the incident is notrec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Ais not present.This st<strong>and</strong>ard is YES if:a. Activity of Individual B after the incident is rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Bis present.7. Activity of the staff after theincident is rec<strong>or</strong>ded.7.a.Staff A (Staff assigned <strong>to</strong> theindividual who is the aggress<strong>or</strong>)This st<strong>and</strong>ard is NO if:a. Activity of Individual B after the incident is notrec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Individual Bis not present.This st<strong>and</strong>ard is YES if:a. Activity of Staff A after the incident is rec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff A ispresent.7.b.Staff B (Staff assigned <strong>to</strong> theindividual who is the Victim)This st<strong>and</strong>ard is NO if:a. Activity of Staff A after the incident is not rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff A isnot present.This st<strong>and</strong>ard is YES if:a. Activity of Staff B after the incident is rec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff B ispresent.8. Surroundings that impacted theincident are rec<strong>or</strong>ded.This st<strong>and</strong>ard is NO if:a. Activity of Staff B after the incident is not rec<strong>or</strong>ded;<strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding activity of Staff B isnot present.This st<strong>and</strong>ard is YES if:a. Surroundings of individuals that impacted the incidentare rec<strong>or</strong>ded; <strong>or</strong><strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 5 of 10
St<strong>and</strong>ard f<strong>or</strong> Supervis<strong>or</strong> Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>InvestigationYes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding the surroundings thatimpacted the incident is rec<strong>or</strong>ded.9. Early warning signs are rec<strong>or</strong>ded.9. Individual A (Aggress<strong>or</strong>)a.This st<strong>and</strong>ard is NO if:a. Surroundings of individuals that impacted the incidentare not rec<strong>or</strong>ded; <strong>or</strong>b. A clear reason f<strong>or</strong> not rec<strong>or</strong>ding the surroundings thatimpacted the incident are not rec<strong>or</strong>ded.This st<strong>and</strong>ard is YES if:a. Early warning signs displayed by Individual A arerec<strong>or</strong>ded; <strong>or</strong>b. It is clearly stated Individual A did not display any earlywarning signs.9.b.Individual B (Victim)This st<strong>and</strong>ard is NO if:a. Early warning signs displayed by Individual A are notrec<strong>or</strong>ded; <strong>or</strong>b. It is not clearly stated Individual A did not display anyearly warning signs.This st<strong>and</strong>ard is YES if:a. Early warning signs displayed by Individual B arerec<strong>or</strong>ded; <strong>or</strong>b. It is clearly stated Individual B did not display any earlywarning signs.10.i.10.i.a.Treatment plans <strong>and</strong> Behavi<strong>or</strong> planswere reviewed <strong>and</strong> interventionstrategies are rec<strong>or</strong>ded.Individual A (Aggress<strong>or</strong>)This st<strong>and</strong>ard is NO if:a. Early warning signs displayed by Individual B are notrec<strong>or</strong>ded; <strong>or</strong>b. It is not clearly stated Individual B did not display anyearly warning signs.This st<strong>and</strong>ard is YES if:a. Intervention strategies from the Treatment plan <strong>and</strong>Behavi<strong>or</strong> Plan (if applicable) f<strong>or</strong> Individual A arerec<strong>or</strong>ded.10.i.b.Individual B (Victim)This st<strong>and</strong>ard is NO if:a. Intervention strategies from the Treatment plan <strong>and</strong>Behavi<strong>or</strong> Plan (if applicable) f<strong>or</strong> Individual A are notrec<strong>or</strong>ded.This st<strong>and</strong>ard is YES if:a. Intervention strategies from the Treatment plan <strong>and</strong>Behavi<strong>or</strong> Plan (if applicable) f<strong>or</strong> Individual B arerec<strong>or</strong>ded.<strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 6 of 10
10.ii.10.ii.a.St<strong>and</strong>ard f<strong>or</strong> Supervis<strong>or</strong> Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>InvestigationInterventions found in the Treatmentplans <strong>and</strong> Behavi<strong>or</strong> plans that wereNOT used that might have been m<strong>or</strong>eeffective are rec<strong>or</strong>ded.Individual A (Aggress<strong>or</strong>)Yes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.This st<strong>and</strong>ard is NO if:a. Intervention strategies from the Treatment plan <strong>and</strong>Behavi<strong>or</strong> Plan (if applicable) f<strong>or</strong> Individual B are notrec<strong>or</strong>ded.This st<strong>and</strong>ard is YES if:a. Intervention strategies from the Treatment plan <strong>and</strong>Behavi<strong>or</strong> Plan (if applicable) f<strong>or</strong> Individual A that wereNOT used that might have been m<strong>or</strong>e effective arerec<strong>or</strong>ded; <strong>or</strong>b. It is clearly stated no other intervention strategiesother than what is described in 10.i.a. were in theTreatment plan <strong>or</strong> Behavi<strong>or</strong> plan f<strong>or</strong> Individual A (ifapplicable.)10.ii.b.Individual B (Victim)This st<strong>and</strong>ard is NO if:a. Intervention strategies from the Treatment plan <strong>and</strong>Behavi<strong>or</strong> Plan (if applicable) f<strong>or</strong> Individual A that wereNOT used that might have been m<strong>or</strong>e effective are notrec<strong>or</strong>ded; <strong>or</strong>b. It is not clearly stated no other intervention strategiesother than what is described in 10.i.a. were in theTreatment plan <strong>or</strong> Behavi<strong>or</strong> plan f<strong>or</strong> Individual A (ifapplicable.)This st<strong>and</strong>ard is YES if:a. Intervention strategies from the Treatment plan <strong>and</strong>Behavi<strong>or</strong> Plan (if applicable) f<strong>or</strong> Individual B that wereNOT used that might have been m<strong>or</strong>e effective arerec<strong>or</strong>ded; <strong>or</strong>b. It is clearly stated no other intervention strategiesother than what is described in 10.i.b. were in theTreatment plan <strong>or</strong> Behavi<strong>or</strong> plan f<strong>or</strong> Individual B (ifapplicable.)11. Interventions staff used bef<strong>or</strong>e,during, <strong>and</strong> after the incident areThis st<strong>and</strong>ard is NO if:a. Intervention strategies from the Treatment plan <strong>and</strong>Behavi<strong>or</strong> Plan (if applicable) f<strong>or</strong> Individual B that wereNOT used that might have been m<strong>or</strong>e effective are notrec<strong>or</strong>ded; <strong>or</strong>b. It is not clearly stated no other intervention strategiesother than what is described in 10.i.b. were in theTreatment plan <strong>or</strong> Behavi<strong>or</strong> plan f<strong>or</strong> Individual B (ifapplicable.)<strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 7 of 10
St<strong>and</strong>ard f<strong>or</strong> Supervis<strong>or</strong> Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>Investigationrec<strong>or</strong>ded.11.a.Staff A (Staff assigned <strong>to</strong> theindividual who is the aggress<strong>or</strong>)Yes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.This st<strong>and</strong>ard is YES if:a. Intervention strategies staff used <strong>with</strong> Individual Abef<strong>or</strong>e, during, <strong>and</strong> after the incident are rec<strong>or</strong>ded.11.b.Staff B (Staff assigned <strong>to</strong> theindividual who is the Victim)This st<strong>and</strong>ard is NO if:a. Intervention strategies staff used <strong>with</strong> Individual Abef<strong>or</strong>e, during, <strong>and</strong> after the incident are notrec<strong>or</strong>ded.This st<strong>and</strong>ard is YES if:a. Intervention strategies staff used <strong>with</strong> Individual Bbef<strong>or</strong>e, during, <strong>and</strong> after the incident are rec<strong>or</strong>ded.12.12.a.Effects of the interventionstrategies are rec<strong>or</strong>ded.Individual A (Aggress<strong>or</strong>)This st<strong>and</strong>ard is NO if:a. Intervention strategies staff used <strong>with</strong> Individual Bbef<strong>or</strong>e, during, <strong>and</strong> after the incident are notrec<strong>or</strong>ded.This st<strong>and</strong>ard is YES if:a. Effects of the Intervention strategies staff used f<strong>or</strong>Individual A are rec<strong>or</strong>ded.12.b.Individual B (Victim)This st<strong>and</strong>ard is NO if:a. Effects of the Intervention strategies staff used f<strong>or</strong>Individual A are not rec<strong>or</strong>ded.This st<strong>and</strong>ard is YES if:a. Effects of the Intervention strategies staff used f<strong>or</strong>Individual B are rec<strong>or</strong>ded.13.Staffing pattern that may haveimpacted the incident is rec<strong>or</strong>ded.This st<strong>and</strong>ard is NO if:a. Effects of the Intervention strategies staff used f<strong>or</strong>Individual B are not rec<strong>or</strong>ded.This st<strong>and</strong>ard is YES if:a. Staffing pattern that may have impacted the incident isrec<strong>or</strong>ded; <strong>or</strong>b. An explanation is present that the staffing pattern didnot impact the incident.14.Sequence of immediate protections<strong>to</strong> eliminate potential, immediate, <strong>and</strong>future harm are rec<strong>or</strong>ded.This st<strong>and</strong>ard is NO if:a. Staffing pattern that may have impacted the incident isnot rec<strong>or</strong>ded.NOTE: This section is similar <strong>to</strong>, but not exactly likeSECURE THE SCENE. Secure the Scene typicallyaddresses IMMEDIATE protections, while this section alsoaddresses protections from potential <strong>and</strong> future harm.This st<strong>and</strong>ard is YES if:<strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 8 of 10
St<strong>and</strong>ard f<strong>or</strong> Supervis<strong>or</strong> Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong>InvestigationYes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.a. Sequence of immediate protections <strong>to</strong> eliminate potential<strong>and</strong> future harm is rec<strong>or</strong>ded (removed the area rug,wiped up spilled liquid, called in w<strong>or</strong>k <strong>or</strong>der, separatedindividuals, additional staff assigned <strong>to</strong> aggress<strong>or</strong>, etc.),<strong>or</strong>b. A clear reason f<strong>or</strong> not describing immediate protectionsis rec<strong>or</strong>ded.15.Description of staff injury, if any, isrec<strong>or</strong>ded.This st<strong>and</strong>ard is NO if:a. Sequence of immediate protections <strong>to</strong> eliminate potential<strong>and</strong> future harm is not rec<strong>or</strong>ded, <strong>or</strong>b. A clear reason f<strong>or</strong> not describing immediate protectionsis not rec<strong>or</strong>ded.This st<strong>and</strong>ard is YES if:a. Staff injury, if any, is rec<strong>or</strong>ded; <strong>or</strong>b. It is clearly stated no staff injury occurred.This st<strong>and</strong>ard is NO if:a. Staff injury, if any, is not rec<strong>or</strong>ded; <strong>or</strong>b. It is not clearly stated no staff injury occurred.St<strong>and</strong>ard f<strong>or</strong> Risk Manager/Investiga<strong>to</strong>rResponsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> F<strong>or</strong>mYes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.1. Analysis <strong>and</strong> Findings are rec<strong>or</strong>ded. This st<strong>and</strong>ard is YES if:a. Analysis <strong>and</strong> Findings are rec<strong>or</strong>ded based on inf<strong>or</strong>mationprovided in the Investigation.This st<strong>and</strong>ard is NO if:a. Analysis <strong>and</strong> Findings are not rec<strong>or</strong>ded based oninf<strong>or</strong>mation provided in the Investigation.2. Facility Follow-up is rec<strong>or</strong>ded. This st<strong>and</strong>ard is YES if:a. Facility follow-up is rec<strong>or</strong>ded based on inf<strong>or</strong>mationprovided in the Investigation; <strong>or</strong>b. It is clearly stated facility follow-up is not warranted.This st<strong>and</strong>ard is NO if:a. Facility follow-up is not rec<strong>or</strong>ded based on inf<strong>or</strong>mationprovided in the Investigation; <strong>or</strong>b. It is not clearly stated facility follow-up is notwarranted.St<strong>and</strong>ard f<strong>or</strong> Team Leader Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> F<strong>or</strong>mYes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.<strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 9 of 10
St<strong>and</strong>ard f<strong>or</strong> Team Leader Responsibility<strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> F<strong>or</strong>m1. A description of how the incidentaffected the individual is rec<strong>or</strong>ded.1.a Individual A (Aggress<strong>or</strong>).Yes<strong>No</strong>CommentsSection may be used <strong>to</strong> clarify a response given, butmay not be used as a st<strong>and</strong>-alone response.This st<strong>and</strong>ard is YES if:a. The incident’s effect on Individual A is rec<strong>or</strong>ded; <strong>or</strong>b. An explanation is present that the incident did not havean effect on Individual A.1.b.Individual B (Victim)This st<strong>and</strong>ard is NO if:a. The incident’s effect on Individual A is not rec<strong>or</strong>ded, <strong>or</strong>b. It is not clearly stated the incident did not have aneffect on Individual A.This st<strong>and</strong>ard is YES if:a. The incident’s effect on Individual B is rec<strong>or</strong>ded; <strong>or</strong>b. An explanation is present that the incident did not havean effect on Individual B.2. If the YES block is checked,indicating additional follow-up isneeded – additional follow-up isrec<strong>or</strong>ded.This st<strong>and</strong>ard is NO if:a. The incident’s effect on Individual B is not rec<strong>or</strong>ded, <strong>or</strong>b. It is not clearly stated the incident did not have aneffect on Individual B.This st<strong>and</strong>ard is YES if:a. The YES box is checked on the investigation ANDfollow-up is rec<strong>or</strong>ded; <strong>or</strong>b. The NO box is checked.This st<strong>and</strong>ard is NO if:a. The YES box is checked on the investigation ANDfollow-up is not rec<strong>or</strong>ded; <strong>or</strong>b. The NO box is not checked, <strong>or</strong>c. Neither the YES <strong>or</strong> <strong>No</strong> box is checked.<strong>DMHDDAS</strong> <strong>Incident</strong> <strong>Rep<strong>or</strong>t</strong> <strong>and</strong> <strong>Peer</strong> <strong>to</strong> <strong>Peer</strong> <strong>with</strong> <strong>No</strong> <strong>or</strong> Min<strong>or</strong> <strong>Injury</strong> Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 10 of 10