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  • Internal Incident Report

    All incidents must be reported within 24 hours of the incident or within 24 hours of when the program became aware of the incident.  A separate form must be completed for each person – do not use identifying information, such as names or initials, if the incident involved another person receiving services.
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  • In the event of death or serious injury, call the Director on call, CEO, and compliance designee. Please call 612-386-0942 

    Serious injuries include the following:

    • Fractures
    • Dislocations
    • Evidence of internal injuries
    • Head injuries with loss of consciousness or potential for a closed head injury or concussion without loss of consciousness requiring a medical assessment by a health care professional, whether or not further medical attention was sought
    • Lacerations involving injuries to tendons or organs and those for which complications are present
    • Extensive second degree or third degree burns and other burns for which complications are present
    • Extensive second degree or third degree frostbite, and other frostbite for which complications are present
    • Irreversible mobility or avulsion of teeth
    • Injuries to the eyeball
    • Ingestion of foreign substances and objects that are harmful
    • Near drowning
    • Heat exhaustion or sunstroke
    • Attempted suicide
    • All other injuries and incidents considered serious after an assessment by a health care professional, including but not limited to self-injurious behavior, a medication error requiring medical treatment, a suspected delay of medical treatment, a complication of a previous injury, or a complication of medical treatment for an injury

     

  • Details of the Incident

  • Staff Response to the Incident

  • Persons Notified

    This MUST be completed within 24 hours of the incident.
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  • Internal Review of Incident

    Items A to C are required for serious injuries, including deaths, emergency use of manual restraint, and alleged or suspected maltreatment. Items D and E are required for ALL incidents.

  • Signatures

    Signatures of staff reporting the incident and staff conducting the internal review are required.
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