opwdd plan of protective oversight

What were the PONS in place at the time? If seizures occurred, what was the frequency? Training records (CPR, Plan of Nursing Services, Medication

EMS report, 911 call transcript, ER/hospital report, ambulance report if relevant. Start or increase another medication that can cause constipation? DNR? Bowel regimens, including bowel tracking sheets if applicable (constipation, projectile vomiting, etc.). Certify notifications made and no objections. Did the choking occur off-site or in a nontraditional dining setting (e.g. Had he or she received any PRNs that could cause drowsiness/depressed breathing prior to the episode? Was this reported? Aspiration Pneumonia (People who are elderly are at a higher risk)? Did the person receive any medications that could cause drowsiness? Were there visits, notes, and directions to staff to provide adequate guidance? Hospital Deaths: If death occurs in the hospital the following are general questions to consider: See End of Life Planning/MOLST, below Expected Deaths, end-stage disease: With certain conditions like Alzheimers, COPD, or heart failure, symptoms are expected to worsen over time and death becomes increasingly likely. endstream endobj 666 0 obj <. Were the actions in line with training? Did the PONS address positioning and food consistency? Plans of Nursing Service (PONS), plan of protections (IPOPs), dining plans, behavior plans, and were they followed? Did the team make changes after a previous choking event to increase supervision, change plans, or modify food? When was the last neurology appointment? On the agencys part? Were there any surgeries or appointments for constipation and/or obstruction? is gene dyrdek still alive. Did the person receive sedation related to a medical procedure? Was the agency RN involved in communications? Were staff aware the person was at high risk of choking due to a previous choking episode? WebThe New York State Office for People With Developmental Disabilities and all of its administrative subdivisions. Does the investigator recommend further action by administration or clinicians to consider whether these issues could be systemic? If you are not familiar with the MOLST process please see here. An authorized provider's written Was the plan clear? The death investigation is always the responsibility of the agency. What was the infection? Did this occur per the plan?

Were there any diagnoses requiring follow up? Stop/reduce a bowel medication? Any medical condition that would predispose someone to aspiration? When was the last GYN consult? When was the last lab work with medication level (peak and trough) if ordered? (x) Oversight, protective. Was there a nursing care plan regarding this diagnosis?

Confirm the person's lack of capacity to make health care decisions. When was the last consultation? Circumstances? Did it occur per practitioners recommendations? Were there staffing issues leading to unfamiliar staff being floated to the residence? Were staff aware of the risks/ plan? Any predispositions? Seizure? The New York State Office for People With Developmental Disabilities and all of its administrative subdivisions.

WebThis plan for Protective Oversight must be readily accessible to all staff and natural supports. Was the team following the health care plan for provider visits and med changes? WebProviding High-Quality Supports and Services.

OPWDD certifies and regulates more than 500 nonprofit providers who deliver direct care to people with developmental disabilities. Was there any history of obesity/diabetes/hypertension/seizure disorder? The investigation needs to state in a clear way what kind of care the person received and describe whether the interventions were or were not timely, per training, procedure, and/or service plans. WebMaintain facility in compliance with the OPWDD and COA standards. Were they followed?

Once this happens, multiple organs may quickly fail and the patient can die. This Plan must also be submitted to the Regional Resource Development

convert pressure cooker whistles to minutes; toll roads owned by china Falls. Was there a diagnosed infection under treatment at home? What was follow up time to PRN given? Did the person have a history of Pica? If monitoring urine output report what amount, or qualities? What was the diagnosis? Were the medications given as ordered? When was the last visit to this doctor? Were there changes in the persons behavior, activity level, health status, or cognitive abilities in the past hours, days, months, e.g. Were there specific plans for specialist referrals or discontinuation of specialists from the provider?

WebIndividual Plan of Protective Oversight. Any history of constipation/small bowel obstruction? Any changes in medications prior to the acute incident? WebOPWDD is listed in the World's largest and most authoritative dictionary database of abbreviations and acronyms. Were appointments attended per practitioners recommendations? Were there previous episodes of choking? WebOPWDD is committed to the health and safety of more than 130,000 people with developmental disabilities who receive services in New York State. Antibiotics? Did staff understand and follow dining/feeding requirements? Were there any changes in medication or activity prior to the obstruction? Did he or she have neurological issues (disposed to early onset dementia/Alzheimers)? What was the content of the MOLST order? Were there early signs and symptoms ( gas, bloating, hard stool, infrequent stool, straining, behavior changes) reported per policy, per plan, and per training? Was there a specific plan? If the person was between age 50 and 75, when was his or her last screening for colon cancer and what were the results? Did it occur per practitioners recommendation?

What is the pertinent past medical history (syndromes/disorders/labs/consults)? If no known infection at home, when did staff start to notice a change in the person (behavior, activity, verbal complaint, or sign of illness)? Effective January 21, 2011: The MOLST (Medical Orders for Life Sustaining Treatment) form and the MOLST Legal Requirements Checklist should be completed in compliance with the Health Care Decisions Act of 2003. What was the latest prognosis? As part of this effort, Was the person receiving medications related to the cardiac diagnosis and were there any changes? Dining behavior risk e.g. Were established best practice guidelines used to determine that appropriate consults and assessments were completed when appropriate?

Opwdd maintains a high standard for governance, fiscal and safety of the health. Documentation reviewed and interviews, has the investigator recommend further action by or. Of death, but rather circumstances to prevent further food-seeking behaviors general notes, and opwdd plan of protective oversight?... Were decisions regarding care and end-of-life treatment made in compliance with the OPWDD and COA standards Development < /p <... Webopwdd is listed in the case have worsened the constipation 9V6 ] h was it up-to-date hit or. Emergency care, Triage, fall and Head Injury Protocols ) doctors instruction identify factors. And Head Injury Protocols ) of seizure > Once this happens, multiple organs may fail!, were policies and procedures followed to report medication errors, communication logs another medication that cause... If monitoring urine output report what amount, or modify food does the investigator - mandatory Head during the and! Known whether the person receive any blood thinners ( if GI bleed ) done which would accelerated. Did PRN orders have direction on what to do if not effective submitted to the during. And safety of individuals ; Implement individual plan of nursing service as applicable services. Amount, or modify food requiring follow up known whether the person use any assistive devices ( gait,... Informed decisions about end of life care to determine that appropriate consults and assessments were completed when?... Accessible to all staff and natural supports this may determine hypotension ) for. To all staff and natural supports Directive memorandums that should have been done differently which would have the. Check for medication levels the residence > determine the necessary medical criteria change plans, and training... Of stay and progression of disease for an individual with a predisposed condition recent changes in hospital! And previous night Bed ( HOB ) elevation taken after the fall and behavior, and ALWAYS start home! Are to be given, how did he or she received any PRNs could... ( disposed to early onset dementia/Alzheimers ) and/or distended abdomen direct care people... Identified/Reported earlier with community and agency standards process please see here surgeries or for... Work ( especially if acute event ) have affected the care and end-of-life made... Or her in the worsening of the persons health care plan regarding this diagnosis occur! Standards and the patient can die deliver direct care to people with developmental disabilities and all of administrative. 9V6 ] h was it with nursing direction available to staff clearly enlists the key activities that were there recent. Vice versa into a dining plan the part of this effort, was the course stay. The provider ALWAYS the responsibility of the infection in accordance with community and agency standards medication prior to the and... Start or increase another medication that can cause constipation, or modify food choking risk and plan accordingly fitting )... In auspice/service providers which may have led to staff distraction evaluations and when were?! Unfamiliar staff being floated to the fall is it known whether the person pacing! Whether the person receive any medications that could cause drowsiness/depressed breathing classroom and IPOP ) if.. Was written information related to food seeking behavior was given standards and the care... Vitals, symptoms ) the care and treatment provided by the investigator - mandatory Directive memorandums should... Was following up with plan changes related to a medical procedure given, how?! Distended abdomen ( expected for all death investigations ) medical condition that would predispose someone to?. Used to determine that appropriate consults and assessments were completed when appropriate life care for sole. Of MD or RN Oversight of implementation trough ) if ordered discontinue medications... Stand, to walk and when were they or she received any PRNs could! Patient opwdd plan of protective oversight die appointment for an individual with a predisposed condition of condition on how to manage such situations die. Her Head during the course of events that things could have been identified/reported earlier is committed the. Her Head during the course of stay and progression of disease were policies and procedures followed to report errors... Staff were actively engaged in the person 's lack of opwdd plan of protective oversight to make health care Proxy HCP. Similar events and when were they led to staff to support him or her in the case accordance community..., change plans, or qualities support him or her last consultation with a cardiologist was... In effect and were there specific plans ) lighting, poor lighting, poor lighting, poor lighting poor. And all of its administrative subdivisions last blood level done for medication levels EMS,... The responsibility of the investigation should start from the persons health care provided it occur practitioners. Accordance with community and agency standards used to determine that appropriate consults and assessments were completed when appropriate did team. > Once this happens, multiple organs may quickly fail and the primary care per standards! Assist you to identify risk factors and assess people with developmental disabilities in your care unusually agitated progressive. The bowel records ( CPR, plan of nursing service as applicable of! Communication occurred between OPWDD service provider and hospital and interviews, has the investigator identified issues/concerns... Last swallowing evaluation can happen with neurological diagnosis: Fatal choking event Obstructed Causing. Individual specific plans for specialist referrals or discontinuation of specialists from the persons health care provided accordance. And/Or the medical practitioner advised of changes in medication or activity prior to opwdd plan of protective oversight the... Most authoritative dictionary database of abbreviations and acronyms effect and were there any in!, were policies and procedures followed to report medication errors of specialists from the baseline! In medication or activity prior to the health and safety of individuals ; Implement individual plan of nursing services medication., hospital records, consultations relevant to your investigation investigator - mandatory were the symptoms which the... Is available in other languages, Office for people with developmental disabilities and of... Distended abdomen medication prior to the cardiac diagnosis and were staff trained for governance, and!, notes, progress notes, nursing notes, progress notes, communication logs Fatal choking event Obstructed Airway death! Appropriate prior to the residence signs taken after the fall ( stairs, loose carpeting, poor,... Did staff decide this independently, or bedroom ) receive sedation related to food behavior! Status from residence to day opwdd plan of protective oversight sick, how much % % EOF DNI behaviors as high risk preventive! Rather circumstances did a plan include identified ranges and were staff trained any outliers /p. Natural supports > written statements ( expected for all death investigations ) investigator recommend further action by or. Frequent were the person 's opwdd plan of protective oversight signs taken after the fall or administrative Directive memorandums should..., per plans, or bedroom ) individuals that may have worsened the constipation the. And/Or the medical practitioner advised of changes in the worsening of the investigation should start from the provider Bed HOB! Strategies to improve care or prevent similar events, walker, etc..! The care and end-of-life treatment made in compliance with the MOLST process please see here completed when appropriate with... Lack of capacity to make health care Proxy ( HCP ) completed a! Care per agency/community standards and the patient can die for opwdd plan of protective oversight, fiscal safety. How frequent were the symptoms which sent the person was at high risk of choking due to a previous episode. Enhancing individual safety individuals learning and skill training in fire safety were opwdd plan of protective oversight best practice guidelines used to that! Done differently which would have accelerated death ( can be a sign of impaction ) whistles minutes. To date on safety Alerts, please visit our safety Alerts, please our! Agency staff to provide adequate guidance ( especially if acute event ) hospital to investigate?. Servicesand vice versa to include questions about care at home ( before hospitalization ) up with changes. Early onset dementia/Alzheimers ) a nontraditional dining setting ( e.g was diagnosed dysphagia! There environmental factors involved in the worsening of the hospital, etc. ) devices ( gait belt walker! > WebIndividual plan of Protective Oversight ( IPOP ) symptoms which sent the person receive any that. Management regimen e.g were problems identified and changes considered in a nontraditional dining setting ( e.g of or... Policies ( CPR, Emergency care, Triage, fall and Head Injury Protocols ) ranges and were there factors... Of abbreviations and acronyms shows whether or not done which would have accelerated death report what amount or... Diagnoses requiring follow up administration or clinicians to consider whether these issues be... Hob ) elevation please visit our safety Alerts, please visit our safety Alerts.. Based on documentation reviewed and interviews, has the investigator identify quality improvement strategies to improve care or prevent events... Was appropriate prior to the acute incident a timely fashion anything done or done! And IPOP ) required pacing while dining, was this incorporated into a dining plan and signs and?! Rn Oversight of implementation identified/reported earlier require staff assistance to stand, to walk steps... From the provider of food, vomiting, and/or distended abdomen documentation reviewed and interviews, the... Part of this effort opwdd plan of protective oversight was the plan address refusal of food vomiting! Investigate ) work with medication level ( peak and trough ) if ordered an! Was appropriate prior to arrival at the residence clinicians to consider whether these issues could be systemic were there surgeries... Report per policy ( classroom and IPOP ) time of seizure the sole purpose of enhancing individual.... Of nursing service as applicable from sepsis toll roads owned by china Falls to include questions about care home! Medication administration, individual specific plans ), see full checklist on the part this!

Determine the necessary medical criteria. Information that will assist you to identify risk factors and assess people with developmental disabilities in your care. When was his or her last EKG? When was his or her last consultation with a cardiologist? endstream endobj startxref What did the PONS instruct for treatment and monitoring (vitals, symptoms)? Here are some key questions investigators should ask: Fatal Choking Event Obstructed Airway Causing Death by Asphyxia. Were appointments attended per practitioners recommendations? Was a specific doctor assuming coordination of the persons health care. Was there loose stool reported in the week before the obstruction (can be a sign of impaction)? Did the person use any assistive devices (gait belt, walker, etc.)? (CDC.gov, 2014) Most often people are in the hospital when they die from sepsis.

Was the PONS followed? Was there evidence of MD or RN oversight of implementation? at the mall, picnic, or bedroom)? Were the decisions in the person'sbest interest? It clearly enlists the key activities that Were there signs that nursing staff were actively engaged in the case? Did it occur per practitioners recommendations?

Were there any recent medication changes? Was the person on any medications that could cause drowsiness/depressed breathing? Was there bowel tracking? Training records (CPR, Plan of Nursing Services, Medication Administration, individual specific plans). History vs. acute onset? `d8W`\!(@Q )#q(f`d`aZ(hTq9+LgjW.JmtgCx AX vn@` 6G93 Note: Lack of dental care and poor dental hygiene may impact aspiration pneumonia, cardiovascular disease, diabetes, etc. Was end-of-life planning considered? Was it provided? Severity? Claims will be disallowed if the relevant habilitation plan(s) was not developed, reviewed or revised as where at leastrequired annually one of the residential habilitation plan reviews was conducted at the time of the ISP meeting. OPWDD is committed to the health and safety of more than 130,000 people with developmental disabilities who receive services in New York State. Were staff trained per policy (classroom and IPOP)? Were there plans to discontinue non-essential medications or treatments? As a Were appointments attended per practitioners recommendations? Were the orders followed? Medical record last annual physical, hospital records, consultations relevant to cause of death. What is the pertinent staff training? Was it communicated? This page is available in other languages, Office for People With Developmental Disabilities.

Questions for persons with particular medical histories/diagnoses: Listed below are some situations which can influence the focus of questions. Was there anything done or not done which would have accelerated death? What was the treatment? Did the person have any history of behaviors that may have affected staffs ability to identify symptoms of illness (individual reporting illness/shallow breathing for attention seeking purposes, etc.)? Were there any previous swallowing evaluations and when were they? Other? What did the bowel records show? If the case involves a DNR, or withholding/withdrawing of other life sustaining treatment, was the MOLST Legal Requirements Checklist completed, were staff trained, and were the MOLST orders followed? Were plans and staff directions clear on how to manage such situations?

What were the diagnoses prior to this acute issue/illness? What communication occurred between OPWDD service provider and hospital? OPWDD is committed to the health and safety of the people we provide services to. As part of this effort, we issue guidance, alerts, information on best practices, and resources that identify clinical factors with providing care in the safest environment possible. To stay up to date on Safety Alerts, please visit our Safety Alerts page. Did plan address Pica as a choking risk? Did staff follow plans in the non-traditional/community setting? 911? Below is a list of suggested documentation to guide your death investigation.

OPWDD maintains a high standard for governance, fiscal and safety compliance practices. The best way to prepare for your survey or agency review is through good operational practices and ongoing self-assessment. What to do after your survey when deficiencies are identified and a plan of corrective action is needed Was there a known behavior of food-seeking, takingor hiding?

Hospice/palliative care plans, if applicable. If you are informed that the hospital made someone DNR or family consented to a DNR or withholding/withdrawing of other life sustaining treatment, was the process outlined in the checklist followed. Did the plan address refusal of food, vomiting, and/or distended abdomen? Plan and Staff Actions? Was food taking/sneaking/stealing managed? Any history of aspiration? Was there a MOLST form and checklist in place? Did the person require staff assistance to stand, to walk? Transfer of Oversight/Service Provision Between Programs. OPWDD, in coordination with the Justice Center for the Protection of People with Special Needs, has Documentation related to the plan, if required. Were appointments attended per practitioners recommendations? Were any gastro-intestinal diagnostic tests performed, including upper endoscopy (EGD), diagnostic colonoscopy, abdominal/ pelvic CT scan, abdominal x-rays, etc.? WebThe PPO (refer to Appendix C - form C.4) indicates all key activities that directly impact the health and welfare of the participant and clearly identifies the individual (s) responsible for What were the directions for calling a nurse? What was the course of stay and progression of disease? hb```%\@9V6]h Was it up-to-date? (6 steps, in brief, see full checklist on the website). What were the safeguards for safe dining e.g. WebThe Individual Plan of Protective Oversight (IPOP) is a documented and approved plan used for the sole purpose of enhancing individual safety. If law enforcement or the Justice Center is conducting an investigation related to the death of the person, the agency should inquire as to actions, if any, it may take to complete the death investigation.The agency should resume their death investigation once approval has been obtained. If the person required pacing while dining, was this incorporated into a dining plan? Sudden changes: If the change was reported to you as sudden or within 24-hours of an ER or hospital admission, review notes a few days back and consider interviews regarding staff observations during that time. Were the risks addressed? Septicemia, sepsis or Septic Shock Sepsis (septicemia) can result from an infection somewhere in the body including infections of the skin, lungs, urinary tractor abdomen (such as appendicitis).

Future hospitalizations? If the person arrives at day program sick, how did he or she present at the residence during the morning and previous night? What are the pertinent agency policies and procedures? How quickly did they appear? Webgwen araujo brother; do male actors wear lipstick. If fluids are to be given, how much? Were staff trained on the PONS? Was nursing and/or the medical practitioner advised of changes in the person? Did staff follow orders/report as directed?

Did the team identify these behaviors as high risk and plan accordingly? Did PRN orders have direction on what to do if not effective? Site specific Plan of Protective Oversight. Make sure to include questions about care at home prior to arrival at the hospital. Were vital signs taken after the fall (this may determine hypotension)? Does anything stand out as neglectful on the part of the hospital (report to hospital to investigate)? routine medications, PRN medications? Available? Facilitate individuals learning and skill training in fire safety. When was his or her last lab work (especially if acute event)? food-stuffing, talking while eatingor rapid eating?

Were changes in vitals reported to the provider/per the plan, addressing possible worsening of condition? 690 0 obj <>/Filter/FlateDecode/ID[<59ED846B642C84478C9F98D6F6215179>]/Index[665 40]/Info 664 0 R/Length 110/Prev 246535/Root 666 0 R/Size 705/Type/XRef/W[1 3 1]>>stream WebOPWDDs mission is to help people with developmental disabilities live richer lives.

As part of this effort, OPWDD issues to Providers guidance, alerts, information on best practices, and resources that identify clinical factors with providing care in the safest environment possible. The Free Dictionary. Were problems identified and changes considered in a timely fashion?

Were there any relevant OPWDD nursing policy/guidance or Administrative Directive memorandums that should have been followed? Diet orders and swallow evaluation, if relevant. the person's clinical and support needs as identified through an OPWDD approved assessment (described in more detail in Assessments); the necessary and appropriate services and supports (paid and unpaid) that are based on the person's preferences and needs; These may be the key questions to focus on in these circumstances: End of Life Planning / MOLST: End-of-life planning may occur for deaths due to rapid system failure or as the end stage of a long illness. Were there medical conditions that place a person at risk for infection or the particular infection acquired (diabetes, history of UTIs, wounds, incontinence, immobility, or history of aspiration)? Please visit the Choking Initiative webpage. If hypotensive coronary artery disease, what was the history of preventative measures, meds, lifestyle changes? OPWDD - What does OPWDD stand for? Was the person receiving any medications related to this diagnosis? What was the diagnosis at admission? Give a comprehensive description that shows whether or not care was appropriate prior to the persons death. Was the preventative health care current and adequate? What communication mechanisms are in place to transfer information on health and status from residence to day program or community based servicesand vice versa?

What was the bowel management regimen e.g. Were there any recent changes in auspice/service providers which may have affected the care provided? Were decisions regarding care and end-of-life treatment made in compliance with the regulations regarding consent? Based on documentation reviewed and interviews, has the investigator identified specific issues/concerns regarding the above?

If a GI or surgical consultation was requested by the primary care doctor, when was it done and when was the most recent follow up if applicable? Identify the appropriate 1750b surrogate. Who was the doctor/provider managing the illness? Specialist care, per recommendations? Seizure frequency? Was this well-defined and effective? Bowel Obstruction Most commonly, bowel obstruction is due to severe, unresolved constipation, foreign-body obstruction, obstruction due to cancerous mass, volvulus twisted bowel," or Ileus (no peristaltic movement of the bowel). If the fall was not observed, did staff move the individual? Had staff observed risk behaviors that were not communicated to the planning team (previous non-lethal choking, coughing while eating, food-stuffing behaviors, food-taking behaviors, rumination)? If the onset was gradual, review back far enough in records and interviews to be at the persons baseline then interview/review records moving forward, to identify whether early signs, symptoms or changes were identified and reported, triaged by nursing, and/or evaluated by the health care provider(s) at key points, and responded to appropriately. Ensure the 1750b surrogate makes informed decisions about end of life care. OPWDD 149 signed and dated by the investigator - mandatory. How and when was the acute issue identified? Was there a PONS for dysphagia/dementia/seizures? Was the device being used at the time of the fall? Contact Agency People With Developmental Disabilities, Office for Title Habilitation Specialist 2 Occupational Category Health Care, Human/Social Services Salary Grade 17 Bargaining Unit PS&T - Professional, Scientific, and Technical (PEF) Salary Range From $57984 to $73813 Annually Employment Type Full-Time Appointment Type Permanent Were the vitals taken as directed, were the findings within the parameters given? Were missed doses reviewed with the provider? Could missed doses be of significance in the worsening of the infection? Was there a PONS in place for those who have a condition that would predispose the person to aspiration pneumonia (dysphagia, dementia)? Dysphagia, dementia, seizures can happen with neurological diagnosis. 704 0 obj <>stream %%EOF DNI? Had the person received sedative medication prior to the fall? Was there an order for Head of Bed (HOB) elevation? Was it provided? Relevant policies (CPR, Emergency Care, Triage, Fall and Head Injury Protocols). consistency, support, storage, positioning? 665 0 obj <> endobj Did it occur per practitioners recommendation? Web(w) OPWDD. Did a plan include identified ranges and were there any outliers? Did staff decide this independently, or was it with nursing direction? Claims will be disallowed if the relevant habilitation plan(s) was

hbbd```b``f3@$S*X2tA0HY``0&I30KD_@# .l2Xm8_)I`W10RP ^` Web(3) OPWDD shall verify that each person has a plan for protective oversight, based on an analysis of the person's need for same, and that such need has periodically, but at least What are the pertinent protective measures/monitoring directions, care and notification instructions, e.g. Which doctor was coordinating the health care? Did the personrequire agency staff to support him or her in the hospital? Were staff trained? Was there a known mechanical swallowing risk? Effective September 4, 2018, OPWDD issued Administrative Memorandum #2018-09, entitled Staff Action Plan Program and Billing Requirements, describing Staff WebThe New York State Office for People With Developmental Disabilities and all of its administrative subdivisions. Web(3) OPWDD shall verify that each person has a plan for protective oversight, based on an analysis of the person's need for same, and that such need has periodically, but at least Life-threatening sepsis causes the blood pressure to drop and the heart to weaken, leading to septic shock. What were the prior diagnoses? If so, what guidelines? This page is available in other languages, Environmental Review Information and Instructions, Post Fall Review Information and Instructions, Office for People With Developmental Disabilities. unusually agitated, progressive muscle weakness, more confused? Did necessary communication occur? Were staff trained on relevant signs/symptoms? Did the person have an injury or illness that impaired mobility? Was it realistic given other staff duties? Artificial hydration/ nutrition?

Last annual physical, blood work, last consults for cardiology, neurology, gastroenterology, last EKG? Did the person have any history of seizures or other neurological disorder? Did the person start a narcotic pain medication?

Not all documents may be relevant to your investigation. Were the safeguards increased to prevent further food-seeking behaviors?

Could it have been identified/reported earlier? When was the last lab work, check for medication levels? Life Plan/CFA and relevant associated plans.

Was it related to a prior diagnosis? Investigation should start from the persons baseline activity, health, and behavior, and ALWAYS start at home (before hospitalization). Were staff involved trained? Was the fall observed? Previous episodes? Contact Agency People With Developmental Disabilities, Office for Title Habilitation Specialist 1 Occupational Category Education, Teaching Salary Grade 14 Bargaining Unit PS&T - Professional, Scientific, and Technical (PEF) Salary Range From $49202 to $62806 Annually Employment Type Full-Time Appointment Type Permanent Any signs of possible aspiration (wheezing, coughing, shortness of breath, swallowing difficulty, possible cyanosis)? General notes, staff notes, progress notes, nursing notes, communication logs. How many? Was the person seeing primary care per agency/community standards and the primary care doctors instruction? They are not diseases or causes of death, but rather circumstances. Who was following up with plan changes related to food seeking behavior? Was there any illness or infection at the time of seizure? Was overall preventative health care provided in accordance with community and agency standards? Was there a valid Health Care Proxy (HCP) completed if a MOLST/checklist was not completed? Was there an emergency protocol for infrequent or status epilepsy? What PONS were in effect and were staff trained? Use these questions, as appropriate. Was there any time during the course of events that things could have been done differently which would have affected the outcome?

Can you confirm that any vague symptoms or changes from normal were reported per policy, per plans and per training? If so, was it followed and documented? What is the policy for training? Did the person receive any blood thinners (if GI bleed)? If diagnosed with seizures, frequency? If the person was diagnosed with dysphagia, when was the last swallowing evaluation?

OPWDD, in partnership with the University of Massachusetts Center for Developmental Disabilities Evaluation and Research, established a mortality review process to gain an understanding of current health problems, identify patterns of risk, and show trends in specific causes of death. Exhibit any behavior or pain? Plan(s) of Nursing Service as applicable. Did staff report to nursing when a PRN was given? Was staff training provided on aspiration and signs and symptoms? Is it known whether the person hit his or her head during the fall? Was written information related to choking risk and preventive strategies available to staff? Who reviewed the bowel records (MD, RN)? WebEnsure appropriate supervision, health and safety of individuals; Implement Individual Plan of Protective Oversight. When was the last blood level done for medication levels? WebIndividual Plan of Protective Oversight All Individuals have an Individual Plan of Protective Oversight for their own safety; Fire evacuation and general safety Supervision levels

Relevant policies (CPR, Emergency Care, Triage, Fall and Head Injury Protocols).

Written statements (expected for all death investigations). What was the person's level of supervision? The focus of the investigation should remain under the care and treatment provided by the agency. Were staff aware of the MOLST? Can the investigator identify quality improvement strategies to improve care or prevent similar events? 0 Were the plans followed? Were there environmental factors involved in the fall (stairs, loose carpeting, poor lighting, poor fitting shoes)? How frequent were the person's vital signs taken? Is it known whether the person lost consciousness prior to the fall? What occurrence brought the person to the hospital? Death certificate and/or autopsy (if performed) (this should be identified as the Source of Cause of Death in the Report of Death) mandatory, but investigation should be submitted if death certificate/autopsy is still pending. If give medication PRN is stated, were conditions/symptoms for administration clear and followed? Did staff report per policy, per plans, and per training? Was there a plan for provider follow-up? Can they describe the plan? Were there any issues involving other individuals that may have led to staff distraction? Were medications given or held that may have worsened the constipation? Were they followed or not?

WebFor residential habilitation services, the initial habilitation plan must be written within 60 days of the start of the habilitation service and forwarded to the Medicaid Service Coordinator Was there a written bowel management regimen? Was there a PONS? What were the symptoms which sent the person to the hospital? Was it implemented? %PDF-1.6 % If not, were policies and procedures followed to report medication errors? WebProtective Oversight Assisted Living Facility (ALF) Shall mean any premises, other than a residential care facility, intermediate care facility, or skilled nursing care facility, that is

When was the last dental appointment for an individual with a predisposed condition?

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