DMHDDAS Incident Report and Peer to Peer with No or Minor Injury ...

Individual Name: Record Individual’s name Incident # Record Incident #DMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation ReviewAudit Tool InstructionsDate of Incident Date of Review Reviewer Investigator/ Team LeaderRecord the date ofthe incidentRecord the date ofthe ReviewRecord theReviewer’s nameInv: Record theinvestigator’s nameTL: Record the TeamLeader’s nameFacilityRecord the name ofthe facilityInstructions: All information to complete the Incident Report Investigation Review is obtained from the Incident Report andPeer to Peer with No or Minor Injury Investigation Review. All Standards should be marked as follows:Individual A = Aggressor, throughout the form Individual B = Victim, throughout the formFor further information related to the Standards, see the DMHDDAS Facility Risk Management Protocol (FRMP) effectiveNovember 1, 2008.Standard for Facility ResponsibilityIncident Report1. All applicable areas on Page 1 of theIncident Report are completedcorrectly.2. All applicable areas on Page 2 of theIncident Report are completedcorrectly.3. All applicable areas on Page 3 of theIncident Report are completedcorrectly.4. All applicable areas on Page 5 of theIncident Report are completedcorrectly.Standard for Facility ResponsibilityPeer to Peer Aggression with No orMinor Injury Investigation5. All applicable areas on Page 1 of thePeer to Peer with No or Minor InjuryInvestigation Report are completedcorrectly.YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.This standard is YES if:a. All applicable areas on Page 1 are completed correctly.This standard is NO if:a. Any applicable area on Page 1 that should have beencompleted is blank or completed incorrectly.This standard is YES if:a. All areas on Page 2 are completed correctly.This standard is NO if:a. Any applicable area on Page 2 that should have beencompleted is blank or completed incorrectly.This standard is YES if:a. All applicable areas on Page 3 are completed correctly.This standard is NO if:a. Any applicable area on Page 3 that should have beencompleted is blank or completed incorrectly.This standard is YES if:a. All applicable areas on Page 5 are completed correctly.This standard is NO if:a. Any applicable area on Page 5 that should have beencompleted is blank or completed incorrectly.CommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.This standard is YES if:a. All applicable areas on Page 1 are completed correctly.This standard is NO if:a. Any applicable area on Page 1 that should have beenDMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 1 of 10

Standard for Facility ResponsibilityIncident Report6. All applicable areas on Page 2 of thePeer to Peer with No or Minor InjuryInvestigation Report are completedcorrectly.7. All applicable areas on Page 3 of thePeer to Peer with No or Minor InjuryInvestigation Report are completedcorrectly.YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.completed is blank or completed incorrectly.This standard is YES if:a. All applicable areas on Page 2 are completed correctly.This standard is NO if:a. Any applicable area on Page 2 that should have beencompleted is blank or completed incorrectly.This standard is YES if:a. All applicable areas on Page 3 are completed correctly.This standard is NO if:a. Any applicable area on Page 3 that should have beencompleted is blank or completed incorrectly.Standard for Supervisor Responsibility:Any “blank” blocks (having zero information or “NA”) in the Investigation should be marked as ”NO,does not meet the standard” in this audit tool.Standard for Supervisor ResponsibilityPeer to Peer with No or Minor InjuryInvestigation1. Immediate steps to SECURE THESCENE are recorded.YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.This standard is YES if, where applicable, the followingitems are recorded:a. First aid or medical care has been provided or obtained(may be found here and/or on Page 3 of the IncidentReport under Medical Assessment); andb. Interventions were put in place to ensure the safety ofall individuals, staff, and other persons, e.g. separationof peers involved and/or other peers as applicable, andc. Photographs were obtained of all visible injuries orphotographs to document that no injury is present; andd. Persons were prohibited from removing or destroyingpotential or actual evidence; ande. Potential witnesses were kept at the scene, andi. Kept separated when possible, while ensuringadequate supervision of all individuals;ii. If separation was not possible, assigned or requestedan additional supervisor to the scene to minimize thepotential witnesses from discussing the incidentamong themselves;iii. Separated as soon as replacement staff coverage isassigned and present, ORf. A clear reason for not doing elements a-e as applicableare recorded.This standard is NO if, as applicable:DMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 2 of 10

Standard for Supervisor ResponsibilityPeer to Peer with No or Minor InjuryInvestigation2. Activity of the individuals before theincident is recorded.2. Individual A (Aggressor)a.YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.a. Elements described in a-e above are not recorded, orb. A clear reason for not doing elements a-e is notdocumented.This standard is YES if:a. Activity of Individual A before the incident is recorded;orb. A clear reason for not recording activity of Individual Ais present.2.b.Individual B (Victim)This standard is NO if:a. Activity of Individual A before the incident is notrecorded; orb. A clear reason for not recording activity of Individual Ais not present.This standard is YES if:a. Activity of Individual B before the incident is recorded;orb. A clear reason for not recording activity of Individual Bis present.3. Activity of the staff before theincident is recorded.3.a.Staff A (Staff assigned to theindividual who is the aggressor)This standard is NO if:a. Activity of Individual B before the incident is notrecorded; orb. A clear reason for not recording activity of Individual Bis not present.This standard is YES if:a. Activity of Staff A before the incident is recorded; orb. A clear reason for not recording activity of Staff A ispresent.3.b.Staff B (Staff assigned to theindividual who is the Victim)This standard is NO if:a. Activity of Staff A before the incident is not recorded;orb. A clear reason for not recording activity of Staff A isnot present.This standard is YES if:a. Activity of Staff B before the incident is recorded; orb. A clear reason for not recording activity of Staff B ispresent.This standard is NO if:a. Activity of Staff B before the incident is not recorded;orb. A clear reason for not recording activity of Staff B isDMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 3 of 10

Standard for Supervisor ResponsibilityPeer to Peer with No or Minor InjuryInvestigation4. Activity of the individuals during theincident is recorded.4. Individual A (Aggressor)a.YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.not present.This standard is YES if:a. Activity of Individual A during the incident is recorded;orb. A clear reason for not recording activity of Individual Ais present.4.b.Individual B (Victim)This standard is NO if:a. Activity of Individual A during the incident is notrecorded; orb. A clear reason for not recording activity of Individual Ais not present.This standard is YES if:a. Activity of Individual B during the incident is recorded;orb. A clear reason for not recording activity of Individual Bis present.5. Activity of the staff during theincident is recorded.5.a.Staff A (Staff assigned to theindividual who is the aggressor)This standard is NO if:a. Activity of Individual B during the incident is notrecorded; orb. A clear reason for not recording activity of Individual Bis not present.This standard is YES if:a. Activity of Staff A during the incident is recorded; orb. A clear reason for not recording activity of Staff A ispresent.5.b.Staff B (Staff assigned to theindividual who is the Victim)This standard is NO if:a. Activity of Staff A during the incident is not recorded;orb. A clear reason for not recording activity of Staff A isnot present.This standard is YES if:a. Activity of Staff B during the incident is recorded; orb. A clear reason for not recording activity of Staff B ispresent.6. Activity of the individuals after theThis standard is NO if:a. Activity of Staff B during the incident is not recorded;orb. A clear reason for not recording activity of Staff B isnot present.DMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 4 of 10

Standard for Supervisor ResponsibilityPeer to Peer with No or Minor InjuryInvestigationincident is recorded.6. Individual A (Aggressor)a.YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.This standard is YES if:a. Activity of Individual A after the incident is recorded;orb. A clear reason for not recording activity of Individual Ais present.6.b.Individual B (Victim)This standard is NO if:a. Activity of Individual A after the incident is notrecorded; orb. A clear reason for not recording activity of Individual Ais not present.This standard is YES if:a. Activity of Individual B after the incident is recorded;orb. A clear reason for not recording activity of Individual Bis present.7. Activity of the staff after theincident is recorded.7.a.Staff A (Staff assigned to theindividual who is the aggressor)This standard is NO if:a. Activity of Individual B after the incident is notrecorded; orb. A clear reason for not recording activity of Individual Bis not present.This standard is YES if:a. Activity of Staff A after the incident is recorded; orb. A clear reason for not recording activity of Staff A ispresent.7.b.Staff B (Staff assigned to theindividual who is the Victim)This standard is NO if:a. Activity of Staff A after the incident is not recorded;orb. A clear reason for not recording activity of Staff A isnot present.This standard is YES if:a. Activity of Staff B after the incident is recorded; orb. A clear reason for not recording activity of Staff B ispresent.8. Surroundings that impacted theincident are recorded.This standard is NO if:a. Activity of Staff B after the incident is not recorded;orb. A clear reason for not recording activity of Staff B isnot present.This standard is YES if:a. Surroundings of individuals that impacted the incidentare recorded; orDMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 5 of 10

Standard for Supervisor ResponsibilityPeer to Peer with No or Minor InjuryInvestigationYesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.b. A clear reason for not recording the surroundings thatimpacted the incident is recorded.9. Early warning signs are recorded.9. Individual A (Aggressor)a.This standard is NO if:a. Surroundings of individuals that impacted the incidentare not recorded; orb. A clear reason for not recording the surroundings thatimpacted the incident are not recorded.This standard is YES if:a. Early warning signs displayed by Individual A arerecorded; orb. It is clearly stated Individual A did not display any earlywarning signs.9.b.Individual B (Victim)This standard is NO if:a. Early warning signs displayed by Individual A are notrecorded; orb. It is not clearly stated Individual A did not display anyearly warning signs.This standard is YES if:a. Early warning signs displayed by Individual B arerecorded; orb. It is clearly stated Individual B did not display any earlywarning signs.10.i.10.i.a.Treatment plans and Behavior planswere reviewed and interventionstrategies are recorded.Individual A (Aggressor)This standard is NO if:a. Early warning signs displayed by Individual B are notrecorded; orb. It is not clearly stated Individual B did not display anyearly warning signs.This standard is YES if:a. Intervention strategies from the Treatment plan andBehavior Plan (if applicable) for Individual A arerecorded.10.i.b.Individual B (Victim)This standard is NO if:a. Intervention strategies from the Treatment plan andBehavior Plan (if applicable) for Individual A are notrecorded.This standard is YES if:a. Intervention strategies from the Treatment plan andBehavior Plan (if applicable) for Individual B arerecorded.DMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 6 of 10

10.ii.10.ii.a.Standard for Supervisor ResponsibilityPeer to Peer with No or Minor InjuryInvestigationInterventions found in the Treatmentplans and Behavior plans that wereNOT used that might have been moreeffective are recorded.Individual A (Aggressor)YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.This standard is NO if:a. Intervention strategies from the Treatment plan andBehavior Plan (if applicable) for Individual B are notrecorded.This standard is YES if:a. Intervention strategies from the Treatment plan andBehavior Plan (if applicable) for Individual A that wereNOT used that might have been more effective arerecorded; orb. It is clearly stated no other intervention strategiesother than what is described in 10.i.a. were in theTreatment plan or Behavior plan for Individual A (ifapplicable.)10.ii.b.Individual B (Victim)This standard is NO if:a. Intervention strategies from the Treatment plan andBehavior Plan (if applicable) for Individual A that wereNOT used that might have been more effective are notrecorded; orb. It is not clearly stated no other intervention strategiesother than what is described in 10.i.a. were in theTreatment plan or Behavior plan for Individual A (ifapplicable.)This standard is YES if:a. Intervention strategies from the Treatment plan andBehavior Plan (if applicable) for Individual B that wereNOT used that might have been more effective arerecorded; orb. It is clearly stated no other intervention strategiesother than what is described in 10.i.b. were in theTreatment plan or Behavior plan for Individual B (ifapplicable.)11. Interventions staff used before,during, and after the incident areThis standard is NO if:a. Intervention strategies from the Treatment plan andBehavior Plan (if applicable) for Individual B that wereNOT used that might have been more effective are notrecorded; orb. It is not clearly stated no other intervention strategiesother than what is described in 10.i.b. were in theTreatment plan or Behavior plan for Individual B (ifapplicable.)DMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 7 of 10

Standard for Supervisor ResponsibilityPeer to Peer with No or Minor InjuryInvestigationrecorded.11.a.Staff A (Staff assigned to theindividual who is the aggressor)YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.This standard is YES if:a. Intervention strategies staff used with Individual Abefore, during, and after the incident are recorded.11.b.Staff B (Staff assigned to theindividual who is the Victim)This standard is NO if:a. Intervention strategies staff used with Individual Abefore, during, and after the incident are notrecorded.This standard is YES if:a. Intervention strategies staff used with Individual Bbefore, during, and after the incident are recorded.12.12.a.Effects of the interventionstrategies are recorded.Individual A (Aggressor)This standard is NO if:a. Intervention strategies staff used with Individual Bbefore, during, and after the incident are notrecorded.This standard is YES if:a. Effects of the Intervention strategies staff used forIndividual A are recorded.12.b.Individual B (Victim)This standard is NO if:a. Effects of the Intervention strategies staff used forIndividual A are not recorded.This standard is YES if:a. Effects of the Intervention strategies staff used forIndividual B are recorded.13.Staffing pattern that may haveimpacted the incident is recorded.This standard is NO if:a. Effects of the Intervention strategies staff used forIndividual B are not recorded.This standard is YES if:a. Staffing pattern that may have impacted the incident isrecorded; orb. An explanation is present that the staffing pattern didnot impact the incident.14.Sequence of immediate protectionsto eliminate potential, immediate, andfuture harm are recorded.This standard is NO if:a. Staffing pattern that may have impacted the incident isnot recorded.NOTE: This section is similar to, but not exactly likeSECURE THE SCENE. Secure the Scene typicallyaddresses IMMEDIATE protections, while this section alsoaddresses protections from potential and future harm.This standard is YES if:DMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 8 of 10

Standard for Supervisor ResponsibilityPeer to Peer with No or Minor InjuryInvestigationYesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.a. Sequence of immediate protections to eliminate potentialand future harm is recorded (removed the area rug,wiped up spilled liquid, called in work order, separatedindividuals, additional staff assigned to aggressor, etc.),orb. A clear reason for not describing immediate protectionsis recorded.15.Description of staff injury, if any, isrecorded.This standard is NO if:a. Sequence of immediate protections to eliminate potentialand future harm is not recorded, orb. A clear reason for not describing immediate protectionsis not recorded.This standard is YES if:a. Staff injury, if any, is recorded; orb. It is clearly stated no staff injury occurred.This standard is NO if:a. Staff injury, if any, is not recorded; orb. It is not clearly stated no staff injury occurred.Standard for Risk Manager/InvestigatorResponsibilityPeer to Peer with No or Minor Injury FormYesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.1. Analysis and Findings are recorded. This standard is YES if:a. Analysis and Findings are recorded based on informationprovided in the Investigation.This standard is NO if:a. Analysis and Findings are not recorded based oninformation provided in the Investigation.2. Facility Follow-up is recorded. This standard is YES if:a. Facility follow-up is recorded based on informationprovided in the Investigation; orb. It is clearly stated facility follow-up is not warranted.This standard is NO if:a. Facility follow-up is not recorded based on informationprovided in the Investigation; orb. It is not clearly stated facility follow-up is notwarranted.Standard for Team Leader ResponsibilityPeer to Peer with No or Minor Injury FormYesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.DMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 9 of 10

Standard for Team Leader ResponsibilityPeer to Peer with No or Minor Injury Form1. A description of how the incidentaffected the individual is recorded.1.a Individual A (Aggressor).YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.This standard is YES if:a. The incident’s effect on Individual A is recorded; orb. An explanation is present that the incident did not havean effect on Individual A.1.b.Individual B (Victim)This standard is NO if:a. The incident’s effect on Individual A is not recorded, orb. It is not clearly stated the incident did not have aneffect on Individual A.This standard is YES if:a. The incident’s effect on Individual B is recorded; orb. 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 isrecorded.This standard is NO if:a. The incident’s effect on Individual B is not recorded, orb. It is not clearly stated the incident did not have aneffect on Individual B.This standard is YES if:a. The YES box is checked on the investigation ANDfollow-up is recorded; orb. The NO box is checked.This standard is NO if:a. The YES box is checked on the investigation ANDfollow-up is not recorded; orb. The NO box is not checked, orc. Neither the YES or No box is checked.DMHDDAS Incident Report and Peer to Peer with No or Minor Injury Investigation Review Audit Tool Instructions-Effective 11/1/08-Page 10 of 10