4/15/10 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21); as required in 42 CPR. 15 483.374 and which have a provider agreement with Alabama Department of Human Resources (DI-IR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of businegs the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 GER. $483332, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of this form to each of the threeiggneies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted Via fax at 4045627435. Document in the residen t?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted Auggst 11, 2013 Report of Serious Occurrence has been placed in resident record Augyst 14, 2013 Centers for Medicare and Medicaid Services Regional Of?ce Alabama Disabilities Alabama Medicaid Agency Advocacy Program Alabama Department of Human Resources Ms. Susan Ward. Dir. Office of ADAP Executive Director Ms. Karen Smith, Program Resource University of Alabama Manager Mental Health 8. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa, AL 35487-0395 Montgomery, Alabama 36104 mg?iisne?r?itgg?ws PO Box 304000 and fax to CMS Montgomery, AL 36130 334-242-1653 205-348-4928 334-353-4945 FAX 404-562-7435 .5321regert@dhr.alabama.gov gsgzuegertQadaguaedu Page 1 of 3 000176 Section 1. Facility Information: 21 Facility/ Program name: Hill Crest Beh?ora] Health Services Street Address/City/Zip 6869 Sta?Avenue South Birmingham,A.labarna 35212 Telephone/Fax 205*838'4034 8384024 Name/Title of person completing report: Denise lones, RN Director of Risk Managem? Section 2. Resident Information: Date of this report February 8, 2016 Date/Time of serious occurrence: February 6, 2016 Approximately 7:00 PM Resident full nam?- Resident date of birth: . csi ent gender: Male (X) Female Resident disability/?diagnosis: Bipolar Disorder with Depression Section 3. Report of a Serious Injurtr to a Resident: _did on Saturday night. 2/6/2016 at approximately 7:00 PM during hygiene time use a metal blade he found outside in a secure area during a scheduled recreational event to in?ict injury upon himself. He made cuts all over his body while in the shower. These cuts were treated with first aide and he was sent to Children's Hospital HR for evaluation and suturesall times, safety precautions were extended and he was placed on suicide precautions. Date/Time of serious injury February 6. 20% Approx. 7:00 PM: Was the resident in restraints or seclusion. at time of serious injuryes. check tyne: Restraint Seclnsion Section 4. Report of a Suicide Attempt by a Resident. stated that his reason for cutting himself when first asltetl was becaUse he did not feel like God wanted im iere anymore. He denies that he was actually trying to kill himself. Then he stated it was because his family was not coming for a visit as originally planner! on 02572016. it was reported that his DHR case worker was notified at 8:05 PM on 2f6f2016 of the incident. She was cooperative and stated understanding. Date/?l ime of incident: 2/6f2016 Approximately HID PM Was the resident in restraints or seclusion at time of suicide attempt? Yes NO liyes.checl< type: Restraint[ Seclusion[ 0001 77 4/15/10 Section 5. Report of a Death of Resident (T he death of a resident, regardless of circumstances or causation. LIST he reported to all agencies listed above, including CMS Regional Office. Please submit Death Reporting Worksheet - to CMS in case of death) Description of the reported immediate cause of death and the events preceding death (attach additional documentation, including incident reports and medical reports): . ..- .. . . Etc/Time of death Was the resident in restraints or seclusion at time of death? Yes No If yes, check type: Restraint Seclusion Section 6. Definitions Race of resident is classified as W(White) B(Black) O(Other, including Native Amen, Asian) Restraint means a ?personal restraint" a ?mechanical restraint? or ?drug used as a restraint.? Personal restraint means the application of physical force without the use of any device, for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to cairn or comfort resident, or holding a resident's hand to safely escort from one area to another. Mechanical restraint means any device attached or. adjacent to the resident's body that hefshe cannot easily remove that restricts freedom of movement or normal access to hisiher hotly. Drug use as restraint means any drug that (1) is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (ll) has the temporary effect of restricting the resident's freedom of movement; and (3) is not a standard treatment for the resident?s medical or concli tion, Sedusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious 112qu means any signi?cant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor, osteopath, podiatrist, dentist, physician's assistant, or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private of?ce through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include, but are not limited to: burns, lacerations requiring sutures, bone fracture, substantial hematomas, internal organ injuries, head injuries and sprains/suspected bone injury leway is ordered. Suicide Attempt is an act that demonstrates some minimal nonvzero intent to die as a result of the act.I This intent can be inferred if the arr could be viewed as potentially lethal by someone or based on the circumstances of the incident, even if no harm actually resulted from the act."! The act under this definition includes implementing any steps to carry out a plan (ie. putting a rope around one's neck).3 A suicide attempt also includes attentionvseeiring conducr if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event, despite the lack of a resulting injury. Therefore, even if no physical injury occurs during a suicide attempt, it should still he reported as a serious occurrence, per. the federal reporting regulations. Assessing and Managing Suicide Risk~Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development, inc. in collaboration with American Association oi?Suicidologi': Revised October 2003, citing ?Columbia Suicide-Severity Rating Scale developed by Posner, Kr, Brent, Lucas Gould, Stanley, 13.; Brown, Fisher, Zelazny, Burke, Oquendo, Mann, 2 Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies For University and College Mental Health Professionals; Suicide Prevention Resource Center, Eduaation Development, Inc. in collaboration with American Association of Suicidology; Revised October 2008. Page 3 of3 000178 Hill Crest Behavioral Hmmsimrim Hill Crest Behavioral Health Services 6869 Avenue South Birmingham, Alabama 35212 Date of Report: February 25. 2016 Date/Time of incidents: Ingmar} 22E 20:6,! 9:00 PM Group Home: ?esserner Groug Home_ Repel-t Received: February 23. 2016 Dar-earm? Narne of Guardian: Race: white Gender: Male Diagnosis: Imguige Disorder 2.Resident?s Name:? Name oquerd? Date of Birth: Race: Elagk Gender: Male Diagnosis: Mood Disorder of Incident: - and-were in a rhysical altercation the evening of February 22"? Before stuff could separate the residents, had Punched-above the left ear and -had received a bruise to his arm. No treatment was required for however complained with a headache. His physician was notified of the Incident. was referred to a local emergency room for evaluation/treatme nt. A C-T of his head was ordered Incl the results were negative for a concussion and no other injuries were noted. His emergenw roam diagnosis was a contusion. returned to the group home the same evening. No further complications have been noted and denied having any problems. Wanda Jordan, RN Asst. Director of Nursing 6869 Fi?h Avenue South Birmingham, Alabama 35212 0 205 833-9000 0001 79 Hill Crest Behavioral Health Services 6869 Avenue South Birmingham, Alabama 35212 Date of Report; Maggi; 12. 2915 Date/Time of incidents: March 14. gogogseo PM Group Home: Begging! grotto Home Report Received: March 19.15 LResldent's Name: Date of Birth:? Race: Black Gender: Male Diagnosis: Conduct Disorder Description of Incident: -ecame extremely agitated with Ms. Woods-case worker and began using profanity threatening her and the group home staff. Then he began to throw furniture, kickinl walls, and yelling screaming, out of control. Staff escorted him to his room away from his peers and Ms. Woods. Due to his out of control behavior the staff noti?ed the Bessemer police. Upon the police arrival,-was still out of control and threatening the staff and peers. The police arrested and place him in jail for his safety and the safety of others. His case worker was in agreement of the police?s action. There were no known physical injuries during this incident. March 17, 2016, the group home manager agreed to accept Herbert back at the group home.- is scheduled to return today. We Wanda Jordan, it Asst. Director of Nursing 0001 80 Hill Crest Behavioral Health Services 6869 5* Avenue South Birmingham, Alabama 35212 Date of Report: March 17: 2016 Date/Time of incidents: March 291615-30 PM Group Home: Bessemer Grgun Home Report Received: March 14. ZOLE 1.Resmem_ sawm? ?am??f?i?a?dia?i? Race: Black Gender: Diagnosis: Disolide: Description of incidiygg: After dinnefa-vas taking out the trash and walked away from the group home. Staff instructed him to return to the group home but he refused. The local police was notified. His DHR can worker was noti?ed ofthe incident. wasretur the [ice It #5 minutes i' rt 0 cr? inalacthri occ rad selo t. his retunh acedon eres ctio s. magma/m Wanda lorda RN Asst. Director of Nursing 000181 4/15/10 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DI-IR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must he submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 CPR. 55483352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence. scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 4045627435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted March 11 2016 3 Report of Serious Occurrence has been placed in resident record March 24., 2D16 Alabama Medicaid Agency Centers for Medicare and Medicaid Services Regional Of?ce Alabama Disabilities Advocacy Program Alabama Department of Human Resources Ms. Susan Ward, Dir. Of?ce of ADAP Executive Director Ms. Jan Sticka,, Program Resource University of Alabama Manager Mental Health 8. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa, AL 35487? Montgomery, Alabama 36104 Eff?i?mf??s?m. PO BOX 304000 0395 and fax to CMS Montgomery, AL 36130 334-242-1653 205-348-4928 334-353-4151 FAX 404-562-7435 334-353-2309 (fax) psv21reportt?gdhralabamaoov psti21reDort@adap.ua.edu Pagcl,of4 0001 82 4/15/10 Section 1. Facility Information: 21 Facility Program name: Hill Crest Behavioral Health Street Addresleitnyip 6869 5th Avenue South Birmingham, Alabama 35% Telephone/Fax T766463 fax Name/1' itle of person completing report: Wandajordan RN Director of Risk Management Section 2. Resident Information: Date of this report March 24, 2016 Date/Time of serious occurrence: March 11. 2016x9200 PM 1.Resident full Name: Name Address Phone of Guardian: Gender: Female Dx: Conduct Disorder Description of Incident: Date/Time of incident: Was the resident in a restraintXSeclnsion at time of incident? Section 4. Report of a suicide Attempt by a Resident: During rounds staff found in the resident?s room, a shoot him in down from a vent which was pulled away from the ceiling. When questioned by staf??stnted she had tried to hand herself. The unit nurse assessed her and noted she had no injury from her attempt, however she did have super?cial scratches on leg which occurred prior to this incident. Her physician placed her on safety and suicide precautions, one to one observation, placed in scrubs for safety and to sleep in the deyroom. Her DHR ci rwas noti?ed of the incident and voiced understanding. Per her thera?eLWhad stated that she had felt overwhelm being here so long. And that she never whant to kill herself and that the sheet was not around her neck. Her therapist believes that her action was de?nite an attention seeking on her part. Her therapist is meeting with her daily. Date/Time of incident:March 11. 2016! 9:00 PM 000183 Was the resident in a restraint/seclusion at time of incident? NO 4/15/10 Section 5. Report of a Death of Resident be death of a resident, regardless of circumstances or causation, MUST be reported to all agencies listed above, including CMS Regional Office. Please submit Death Reporting Worksheet - to CMS in case of death) Description of the reported inunediate cause of death and the events preceding death (attach additional documentation, including incident reports and medical reports): Date/Time of death_ Was the resident in restraints or seclusion at time of death? Yes No If yes, check type: Restraint[ Seclusion[ Section 6. Definitions Race of resident is classi?ed as W(VVhite) B(Blacl<) H(Hispanic) 0(Other, including Native Amen, Asian) Restraint means a ?personal restraint? a ?mechanical restraint? or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device, for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to calm or comfort resident, or holding a resident's hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that cannot easily remove that restricts freedom of movement or normal access to hisfher body. Drug use as restraint means any drug that is administered to manage a resident?s behavior in a way that reduces the safety risk to the resident or others; 2) has the temporary elfecr of restricting the resident's freedom of movement; and (3) is not a standard treatment for the resident's medical or condition. Sedusr'on means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leavin . Serious Injury means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath, podiatrist, dentist, physician's assistant, or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the dostor?s private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include, but are not limited to: burns. lacerations requiring bone fracture, substantial lionatomas, internal organ injuries, head injuries and sprains/suspected hone injury ivatty is ordered. Sufcrn?e Attempt is an act that demonstrates some minimal nonazero intent to die as a result of the act.I This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident, even if no harm actually resulted from the act.2 The act under this definition includes implementing any steps to carry out a plan (to. putting a rope around one?s neck).l A suicide attempt also includes attentionwsecking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event, despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development. Inc. in collaboration with American Association of Suicidologi?; Revised October 2003, citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner, Brent, Lucas Gould, Stanley, 13.; Brovrn, Fisher, Zelazny, Burke, Oqucndo, 2 Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development, Inc. in collaboration with American Association of Suicidology; Revised October 2008. Page 3 of 4 000184 4/lS/10 injury. Therefore, even if no physical injury occurs during a suicide attempt, it should still be reported as a serious occurrence. per the federal reporting regulationst Page 4 of4 000185 4115/10 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. Si 483.374 and which have a provider agreement with Alabama Department of Human Resources (DI-1R). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 CPR. 6483.352, or suicide a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition; please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the MS regional office may be submitted via fax at 4046627435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: March 24 2016 Report of Serious Occurrence has been placed in resident record March 25, 2016 Centers for Medicare and Medicaid Services Regional Ol?ce Alabama Disabilities Alabama Medicaid Agency Advocacy Program Alabama Department of Human Resources Ms. Susan Ward, Dir. Of?ce of ADAP Executive Director Ms. Jan Sticks, Program Resource University of Alabama Manager Mental Health 8. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa. AL 35487? Montgomery, Alabama 36104 RPLegajriIEOJnrj?f?s'? PO BOX 304000 0395 and fax to one Montgomery, AL 36130 3134-3534151 FAX 404-562-7435 334-242-1653 205-348-4923 334-353-2309 (fax) 953,521regedehralabamagov Page 1 of 4 000186 4/15/10 Section 1. Facility Information: 21 Facility/ Program name: Hill Crest Behavioral l-Iealth? i?Iigdon Hill Group Home Street Address/City/Zip 6869 Avenue South Birmingham. Alabama 35212 Telephone/Fax 205?838-2076! 7756463 fax Name/Title of person completing report: Wanda lordan RN Director of Risk Management Section 2. Resident Information: Date of this report: March 25, 2016 Date/Time of serious occurrence: March 24, 2016f4230 PM .Resident full NameLResident date of birth: ardian: Race: Gender: Male Dx: Conduct Disorder Deseription of Incident: gate/Time of incident: Was the resident in a restraintfseelnsion at time of incident? Section 4. Report of a suicide Attempt by a Resident: was out of control, cursing, making inappropriate remarks about himself and his therapist. Hejumped upon his bed and attempted to place his belt over the light fixture. He stated he wanted to die. The staff was within arm length at this time and was trying to process with him. He ?nally got clown and sat on his bed. He was allowed to ventilate his feeling to the staff. He stated he was tired being at the group home and wanted to leave. His physician was noti?ed and was placed him on suicide precautions and one to one observation while asleep. Staff is to continue to monitor him for any selfharm behaviors. Upon assessment, the nurse noted no injuries occurred during this incident. Staff stated the belt was never completely around his neck. He was never in any actual harm due to the fact the staff was within arm reach. The therapist is meeting with him daily. gate/Time of incident: March 24. PM 000187 Was the resident in a restraint/seclusion at time of incident? NO 4/15/10 Section 5. Report of a Death of Resident (The death of a resident, tega rdless of circumstances or causation, MUST be reported to all agencies listed above, including CMS Regional Of?ce. Please submit Death Reporting Worksheet . to MS in case of death) Description of the reported immediate cause of death and the events preceding death (attach additional documentation, including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No If yes, check type: Restraint[ Seclusion Section 6. Definitions Race of resident is classified as WON/hire) B(Black) H(Hispanic) O(Other, including Native Amen, Asian) Restraint means a ?personal restraint" a ?mechanical restraint" or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device, for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident, or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident's body that hefshe cannot easily remove that restricts freedom of movement or normal access to hisi'her body. Drug use as restraint means any drug that (1) is administered to manage a resident?s behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident?s freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. Seclusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious Injury means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor, osteopath, podiatrist, dentist, physician's assistant, or nurse pracritloner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care hospital Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include, but are not limited to: burns, lacerations requiring sunircs. bone fracture, substantial hematomas, internal organ injuries, head injuries and bone injury ifJC?rny is ordered. Suicide Attempt is an act that demonstrates some minimal non'zero intent to die as a result of the act.1 This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.2 The act under this definition includes implementing any steps to carry out a plan (ie. putting a rope around one's neck).1 A suicide attempt also includes attentionrsecking conduct if the conclutt can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk?Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development, Inc. in collaboration with American Association of Suicidology; Revised October 2003, citing?Columbia Suicide-Severity Ruling Scale developed by Posner, Brent, Lucas Gould, Stanley, 13.; Brown, Fisher, Zelazny, Burke, Oqucndo, Mann, 2 Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development, inc. in collaboration with American Association of Suicidology; Revised October 2008. Page 3 of 4 0001 88 4/15/10 injury. Therefore, even if no physical injury occurs during a suicide attempt, it should still be reported as a serious occurrence, per the federal reporting regulations. Page 4 of 4 0001 89 4/ 4.26.2016 To: DHR Pram: Bernittaae Richardson, RN Fax: 205-776-6463 2 Phone: 205-833-2076 Date: 4.26.2016 Re: Incident CC: Urgent [1 For Review Please Comment Please Reply Plcase 000190 Hill Crest Behavioral Health Services 6869 5th Avenue South Birmingham, AL 35212 Date of Report: April 26, 2016 Date/Tone of Incidents: April 25, Group Home: Bessemer Group Home Report Received: April 26, 2016 Resident?s Name: Date of Birth: - Name of -?noti?ed by Program Manager at 4/25/2016 Race: Black Gender: Male Diagnosis: Conduct Disorder Description of Incident: Residen_ eloped April 25, 2016 at approximately 3:07pm ?ow. the fiont of the hospital as he was boarding the van to retUm to Bessemer. Staff attempted to apprehend him but Was unsuccess?zl. The police were called and a police report was ?led. Case DHR Was noti?ed. -wes returned to the hospital lobby by Birmingham Police Department at4:50p.n1. No criminal behaviors or injuries noted. Bernittae Richardson RN Lu? 6 Hillcrest Behavioral Health 6869 5?1 Avenue South Birmingham, AL 35212 (205) 833-9000 ext 2076 000191 ?7!wa 4.28.2016 To: DHR From: Remit-tat: Richardson, RN Fax: 334653-2693 Pages: 2 Phane: 205-833?9000 ext. 2076 Date: 4.28.2016 Re: Incident CC: Urgent For Review Prensa Comment '1 Please Reply Please Recycle Comments: [Type comments] 000192 Hill Crest Behavioral Health Services 6869 St Avenue South Birmingham, AL 35212 Date of Report: April 28, 2016 Date/Time of Incidents: April 27, GrouP Home: Bessemer Group Home Report Received: April 28, 2016 Resident?s Name: Date of Birth: Name of Guardian: -noti?ed by Program Director at 4/25/2016 Race: Black Gender: Male Diagnosis: Conduct Disorder Des ri tion of i eat: Resident-was taken to Children?s Hospital on 04/27/2016 at 9:45pm. Pt became very upset locked-himself in the ?ierapist?s of?ce, broke a vase and stated that he wanted to kill hirnself. _was taken to Children?s ER for evaluatiOn per MD order. Pt was admitted to the ER awaiting a bed on unit. Pt was escorted to ER by staff member Carmen Underwood. Dwight Horton, staff, is with him this moming until a bed becomes available. Bemittae Richardson, RN (A) a ,05 Hillcrest Behavioral Health 6869 Avenue South Birmingham, AL 35212 (205) 333-9000 ext 2076 000193 To: DHR From: Barnittac Richards an. RN Fax: 334-353-2693 Pages: 5 Phone: Data: 5 .9.2016 Re: CC: urgent For Review Please Comment Please Reply Please Recycle Comments: Any questions, feel free to call me at 205-833-2076 5.9.2016 000194 Hill Crest Behavioral Health Services 6869 Avenue South Alabama 35212 Date of Rapar't; Mag 9. auto Date/Time of Incidents: Mar 8. 2915/1529 rm Group Home: Rigger! Girls Groug Home Report Received: My g, 2016_ Resident? 5 Name: Date of Birth? Name of Guardian Race: White Gender: Female Diagnosis: MM gesgrimion of incident: -reportad that she was inappropriately touched by a peer while sitting and watching TV in dayronm. _stated that caused her trauma. Thlraplst contacted DHR worker who stated that wanted to press charges. Local pollen was called and report was made. Case number is -DHR was made are that police report had been ?led per pt?s request. Bernittae Richardson, RN Clinical Nurse Manager 000195 Hill Crest Behavioral Health Services 6859 Avenue South Birmingham, Alabama 35212 Date of Report: Mg]: 2. 2016 Date/Time of Incidents: May a, 2016! 1025 PM Group Home: Higden Boys Gregg ?ame Report Received: May 9: 2016 Resident?s Name: Date of Birth? Name oquardian: Race: Black Gender: Male Diagnosis: Connie-:3 Qigerder Descrimigu 9f Inciggng: .pushed past stuff and ran away from the group home. Staff was unable to apprehend resident. The local police were notified. Group Home Director was noti?ed. Resident was returned by local police at 1050 pm. No criminal acts were performed while away from facility. DHR was noti?ed of elopement and that patient had returned. Bernittae Richardson, RN Clinical Nurse Manager 000196 Hill Crest Behavioral Health Services 6869 Avenue South Birmingham, Alabama 35212 Date of Report: May a. 2016 Date/Time of incidents: Ma: Q, Z?l?i PM Group Home: Higdon Bogs Groug Home Report Received: My 9, 2015 Resident?s Name: Date of Birth- Name of Guardian: Race: white Gender: Male Diagnosis: momenta of incident: was named in an allegation for inappropriately touching peer. .tated peer's WWI calling him "gay" so he wanted to prove that he was not. - in the presence of his therapist. acknowledged that he did [no ro riatelv touch his poor. DHR was noti?ed and made aware of the allegation and admittance. ?as placed on constant observation for safety. mama) Bernittae Richardson, RN Clinical Nurse Manager 000197 BIRMINGHAM POI-ICE nemamem GASE INFORMATION CARD ASE MUMEE Mon EMERGENDY YOUR SHOILD BE READYWITHIN 48 HOURS- HEGDH 0001 98 5-10.2016 Tm DHR From: Remit-hue Richardson. RN Fax: 334?353-2693 Pages: 3 Phone: Deter 5.10.2016 Re: Incidents CC: Urgent For 12.:ch Please Comment Please Reply Please Renycl: Comments: 000199 Hill Crest Behavioral Health Services 6869 5th Avianue South Birmingham, Alabama 35212 Date of Report: Ma}: 31,2015 Date/Time of Incidents: April 19, 2016Iunknown Group HomE: Higgon Lilli Girls Group Home Report Received: May 9. 2010 Resident?s Name:? Date of am! Race: White Gender: Female Diagnosis: Conduct Disorder Desggiptign of Incident: -mporl:ed to the weekend staff that a peer forced her to perform oral sex while in sehool in early April. On Mon day, durin session with therapist, peer was questioned and stated that it did happen but it was consensual.ithirapist spoke with her and asked for another statement and she stated that it did happen and that it was consensual. After further Investigation-Has placed on precauthns and house restriction. DHR was noti?ed. Action plan developed for both peers. Bernittae Richards?, RN Clinical Nurse Manager 000200 Hill Crest Behavioral Health Services 6359 Avenue South Birmingham, Alabama 35212 Date of Report: My 10. 2016 Date/Time of Incidents: 3ij 19: 201g: Group Home: Higdnn Bots Grow Home Report Received: My 3. 2916 Resident?s Name: Date of Birth Race: White Gender; Male Diagnosis: ggndug; Q?mgrder of incident; to his therapist on yesterday that he and another peer had been sexually acting out and that the peer had performed oral sex for him. He also stated that It was consensual. He said that it happened du ring school hours In earlyApril. He also stated that this was only time this had happened between the two of them. After further invustigatlon and speaking with the peer,- was placed on precautions and house restriction. DHR was noti?ed. Bernittae Richardson, RN Clinical Nurse Manager 000201 5. 10.20 16 To: DHR Prom: Bcruitme thhardson, RN Fax: 334-353-2693 Pages: 3 Phone: Data: 5.10.2016 Re: Incidents CC: Urgent For Rcvicw Please Coma-at El Please Reply Please Recycle 000202 Hill Crest Behavioral Health Services 6369 5"1 Avenue South Alabama 35212 Date of Report: May 10.:915 Date/Time of Incldents: Aprll 19, 29;5?gplmown Group Home: ngdon Hill-Girls Group Home Report Received: May 9. 2m Resident's Name: Date of Birth Name of Guardian?? Race: White Gender: Female Diagnosis: Congugt Dispzder Des i of Incident: -reported to the weekend staff that a peel-forced her to ?perform oral sex whlle in school In early April. On Monday, during sosslon with therapist, peer was questioned and stated that it did happen but it was consensual. -therepist spoke with her and asked for another statement and she stated that it happen and that It was consensual. After further Investigation-Wis placed on precautions and house restriction. DHR was noti?ed. Action plan developed for both peers. I Bernitt?ac Rlchardson, RN Nurse Manager 000203 Hill Crest Behavioral Health Services 6869 Elm Avenue South Birmingham, Alabama 35212 Date of Report: May 10. 2016 Date/Time of Incidents: Agril 19II 201?? unknoyyn Group Home: Eggs ?roug Home Report Received: May 9. 2016 Resident?s Name: Date of Birth? Name of Guardian: Race: White Gender: Mal; Diagnosis: Conduct Descrl tion ofl nt: to his therapist on yesterday that he and another peer had been sexually acting out and that the peer had performed oral sex for him. He also stated that it was consensual. He said that it happened during school hours in early April. He also stated that this was the only time this had happened between the two of them. After further investigation and speaking with the peer. wme restriction. DHR was noti?ed. Bernittae Richardson, RN Clinical Nurse Manager 000204 m. 543.2015 To: DHR From: Remittac Richardson, RN Fax: 334.- 353-2693 - Pages: 3 Phone: Date: 5.13.2016 Ru: Hospitalizaulon CC: Urgent El Fochvimr CI Flew: Chm-mm Hem chiy Plans: Rhys-3c Comments} 000205 Hill Crest Behavioral Health Services 6369 5?h Avenue South Birmingham, Alabama 35212 Date of Report: Mag 13, Zgl? Date/Time of incidEnts: Mg! my goal PM Group Home: _i-_i_ideon Hill Bogs Group ?ame Report Received: May 13? 3016 Resident's Nam=_ Date of Birth? Narne of Guardian: Race: White Gender: Male Diagnosis: Deso ton lnciden: -was transferred to Adolescent ACute Unit for stabilization of medication. MD teeis that patient has a decline and needs medication adjustments. Over the past few weeks, as attempted to alope, invoked In multiple altercations with peers, and increased aggression accompanied with property or e. DHR was noti?ed and agreed with transfer. mg; Bernit'tae Richardson, RN Clinical Nurse Manager 000206 5.112015 To: From: Ben?ttae Richardson, RN Fax: 334653-2693 P0305: 2 Phone: Data: 5.17.2016 Re: Incident CC: Urgent Cl For Review Please Comment Please Reply Please Recycle Comments: 000207 Hill Crest Behavioral Health Services 6869 Avenue South Birmingham, Alabama 352.12 Date of Repomlviag 2016 Date/Tlme of Incidents: Mag 16, 213mm; AM Group Home': Bessemer Group Home Report Received: May 16.2g1? Resident'swame? Barnum:? Name of Guardian: Race: White Gender: Male Diagnosis: Conduct DisordEr Desolation of Incident: walked away from the group home without permission. Staff was unable to locate resident and notified the local police. Group Home Director was cantactad. DHR was noti?ed. Local police returned DBEIDAM. No criminal acts were committed while away from the facility. After questioning therapist reported that -stated that he ran away because his mother stated that she could not him up for a pass. Bernittae Richardson, RN Clinical Nurse Manager 000208 5.17.2016 T0: DHR . From: Bernittae Riglyn'dson. RN Fax: 33445 3-2593 Pages: 2 Phonic: ?Date: 5. 1 7.2016 Re: Incident CC: Urgent For Rcview Please Camment Please Reply ?3 Please Recycle Comments: 000209 Hill Crest Behavioral Health Services 6869 5th Avenue South Birmingham, Alabama 35212 Date of Report: Mag 17. 2016 Date/Time of incidents: May 16, 2013.! 3:45 AM Group Home: Bessemer Group Home Report Received: May 16! 2016 Resident?s Name: Date of Birth: Na me (sf Guardian: Race: White Gender: Male Diagnosis: anduct Disgrder of incident: - walked away from the group home without permission. Staff was unable to locate resident and noti?ed the local police. Group Home Director was contacted. DHR was noti?ed. Local police returned at 0930AM. No criminal acts were committed while away from the facility. After questioning therapist reported that- stated that he ran away because his mother stated that she could not pick him up for a pass. Bernittae Richardson, RN Clinical Nurse Manager 000210 5.23.2016 To: DHR From: Bet-mm Richardson, RN Fax: 334-353?2693 Pages: 3 Phone: Date: 5.23.2016 Re: Incidents CC: Urgent For Review Please Comment Phage Reply '3 Please Recycle Comments: 00021 1 Hill Crest Behavioral Health Services 6869 5th Avenue South Birmingham, Alabama 35212 Date of Report: May 23, 24316 Date/Time of incidents: May at. 201M235 AM Group Home: gossamer Bag; Group Home Report Received: May: 3016 Reside nt?s Name:_ Date of Birth Name of Guardian: Race: Caucasian Gender: Male Diagnosis: conduct Qisorggr Description of _loped from Bessemer Bay: Group Home on 5/21/2016. Per report, patient was on elopement precautions which prevented him from leaving the group home. As his peers were getting ready to leave BBGH for school, patient bolted past staff and out the front door. Staff was unable to locate resident and noti?ed the local police as well as Jefferson County DHR Social Worker. At the time of this writing, will not be returning to the group home and his whereabouts remaln unknown. coo Stephen L. Murphy. MSW, LGSW Director of Risk Management 000212 Crest Behavioral Health Services 5359 5??Avcnue South Birmingham, Alabama 35212 Date of Report: MAM Date/Time of Incidents: Mag Z?l??am? PM Group Home: Bessemer 3W5 Grail-m Home Report Received: May 22, 2016 Resident?s Name:_ Date of Birth? Name of Guardian: Race: Black Gender: Male Diagnosis: unspecified Mood {Affirm of incident: - along with two other male peers, oloped from Besserner Boys Group Home on 5/22/2016. They pushed a window out, kicked a hole In group home director?s door to open the lock, and stole money and receipts from the safe located in the of?ce. Staff was unable to locate resident and noti?ed the local polka as We? as Jefferson County DHR Social Worker. At the time of this writing, ill not be returning to the group home and his whereabouts remain unknown. tephen L. Murphy, MSW, LGSW Director of Risk Management 00021 3 Hill Crest Behavioral Health Services 6869 5??Auenue South Birmingham, Alabama 35212 Date of Report: May 23. 201$ Date/Time of Incidents: MW 22. 201 53:00 PM Group Home: Bessemer 3913 group Home Report Received: Ma! 31216 Resident?s Name:? Date of Birth Name of Guardian: Diagnosis: Unsgegified Mood (Affective) DID Race: ?it?cit Dogcrigtion of Incident: along with two other male peers, cloned from Besserlmr Boys Group Home on Per mourn?pushed a window out, the other peer kicked a hole in group home director's door. and they stole money and receipts from the safe located in the of?ce. Sta? was unable to locate resident and notified the local police as well as Mobile County DHR Social Worker. At the time of this not be returning to the group home and his whoroabouts remaln unknown. ophen Murphy, MSW, Director of Risk Management 00021 4 Hill Crest Behavioral Health services 6869 Avenue South Birmingham, Alabama 35212 Date of Report: May: 23.;016 Date/Time of Incidents: Mar 22, 2016/3110 PM Group Home: gessemer Heirs Gregg Home Report Received: May 22. 2016 Resident?s Name:_ Date of Birth? No me of Guardian: Race: Black Gender: Male Diagnosis: Uns ecifle Aft 0 Description of Incident; - along with two other male peers, elopeol from Bessemer Boys Group Home on 5122/2016. Per report, one peer pushed a window nub-kicked a hole in group heme director's door to open the lock, and they stole money and receipts from the safe located in the of?ce. Staff was unable to locate resident and notified the local police as wall as Mobile County DHR Social Worker. At the time of this writing, will not be returning to the group home and his whereabouts remain unknown. L. Murphy, MSW, LGSW Director of Risk Management 00021 5 527.2016 To: DHR From: Remittac Richardson. RN Fax: 33+353-2693 Pages: 6 Phone: Date: 527.2015 Re: GEE: Urgmt For Row-icw Please Comment Pleas: Reply Please Recycle Fomments: 000216 Hill Crest Behavioral Health Services 6869 5':th Avenue South Birmingham, Alabama 35212 Date of Report: Mg: g7, 2915 Date/Time of incidents: MM Group Home: Bessemer G_roup Home Report Received: My 27! 2:116 Resident?s Name: Date of Birth? Name of Guardian: Race: Black Gender: Male Diagnosis: Mead giggrgeg Descri ?rm of! 1 t: Due to Bessemer Boys Group Home closing-was admitted to RT: residential unit. was [113 aware. Stephen Murphy, MSW LGSW Director of Risk Management 000217 Hill Crest Behavioral Health Services 6869 5th Avenue South Birmingham, Alabama 35212 Date of Report: Mu 25: 2015 Date/Timur: of Mag 25, 2915;! PM Group Home: Be?gmer Grout; Home Report Received: My 35. 2016 Resident?s Name: Date of Birth? Name of Guardian: Gender; Male Diagnosis: gigolar Disgxg?]: weal pallce was noti?ed and- eloped from Bessemer Bay: Group Home on May 22, 2018. was admitted to RTC as returned via police. Duo ta Bessemer Boys Group Hom? closing, residential unit. DHR was made aware. Stephen Murphy, MSLN LGSW Director of Risk Management 00021 8 Hill Crest Behavioral Health Services 6869 Avenue Sauth Birmingham, Alabama 35212 Date of Report: May 2'1. 2016 Date/Time of Incidents: Mag 25. 20162 14:07 PM Group Home: (jmug Home Report Received: Mg}; 2016 Resident?s Name: Date of Birth Name of Guardian: Diagnosis: Malar anzegsive Disorder Anace: Black Gender: Male of Incident: Due to Bessemer Boys Group Home closlng,-was admitted to ngdon Boys Group Home. DHR was made. aware. 4 .. ILL tephen Murphy, MSW LGSW Director of Management 000219 Hill Crest Behavioral Health Services 6869 Avenue South Birmingham, Alabama 35212 Date of Report: May 27, 2:116 Date/Time of Incidents: Mag 25. ?1161i 13:22 PM Group Home: Bessemer Graug Home Report Received: May 2016 Reside nt?s Name: Date of Birth- Name of Guardian: hate: gaucaglan Gender: Male Diagnosis: lmgulse Disorder inescrigtian of incident: Due to Bemrner Bays Group Home closing- DHR as made aware. was Idmitted to ngdun Hill boys Group Home. Irh??ic?rg when Murphy, MSW LGSW Director of Risk Management 000220 Crest Behavioral Health Services 6869 5'?1 Awnua South Alabama 35212 Date of Report; May 2016 Date/Time of Incidents: My 26, 20mg 14:46 EM ?Group Home: Bgssemg: Gmug Home Report Received: My 27, 2st Resident?s Name: Date of Birth- Name of Guardian: FRace: Caucasian Genderm Diagnosis: Congug; Qisorder 9f Due to Bessemer Boys Group Home closing,-Mls admitted to HTC residential unit. mm was made aware. Stephan LGSW Director of Risk Management 000221 FROM1HIGDUN HILL GROUP Hi3 3958354849 TU: 1.334353269353479 P. 1 Crestl?lgdon Hill 24 Hour Occurrence once i ck) RwidemNamm Ago: I 3/ Occurrence Time/Date: __1_u_ne/15 (ii) 9:33p Occurrence location: Elation E111 Group erue Verbal ?g??entlon [mm edict: noti?cation must be provided within 24 hours alter the occurrence or the ?rst work dey following the occurrence. whichewr is sooner. A representative ?om Higdon Hill untet It'erlielh,r content Rochelle Sharp, Higdon Hill Assistant Director or the covering House Supervisor IF the occmrencc takes place on the weekend Ambit} WITH. local admitting county Dim AND Gloria (Dot-ice) Holloway, State Department of Human Resom'cee, O?icc of Lioensure 1*334-242-81 77. In addition, Wanda Jordan, Hill Crest Risk Manager must be noti?ed as the program must submit a report to State DER. Of?ce ofLicensure within 5 days of the occurrence. Higdon Hill Program Director noti?ed on INIME 9:33]: by Brandon Stockton (duto?tirue) (stuff nameititle) Type of noti?cation provided (circle applicable): accusation. telephone voiccmuil message, tinted occurrence notice House Supervisor noti?ed on by (11.8. name) (date/lime) Type of noti?cation provided (circle applicable): fl'gigph one converggtim, telephone voiccrnail message, faxed occurrence notice Mgh?e County DHR after hours noti?ed on ?ame @stigog by re (dateltimc) (See attached phone list for admitting county utter-hours contact number) Type of noti?cation prow'ded (circle applicable): Telephone conversation, telephone voicemnil message, faxed occurrence notice Name of After-hours worker that responded to the occurrence [Sage not recorded date/time 10/16!16 2:302 Re?nance From worker cut/wing the call: State DHR, Gloria Holloway noti?ed on l?il'?l? 13*331: by Rochelle ?gugMaI-hugg [mag i (date/time} (staff name/title) Type of noti?cation provided (circle applicable): Telephone conversation. telephone voicemail message, faxed oecm-reoce notice Approved family members noti?ed: Yes N?ll'lci'rcln?unship of Person noti?ed Noti?ed on by (dramatic) (staff nameltitle) Type of noti?cation provided (circle applicable): Telephone conversation, telephone voicemail massage. faxed notice *"Piease list the County called and contact number called Please select the following: til Client Injtn'y-All injuries requiring medical treatment for any client at the facility or while participating in o?i-site activities Self'Injury Accident Other 02 Client illness-any illness deeming at the facility or while participating in ctr-site fhcility activities which required professional medical treeme 3: Known Please note. i?when client re?ned to it Yes No Date of rotten 6 It (I 04 Suicidal (client made an attempt to cause harm to reoehred professieml medical treatment) 05 Death (Any death occumlgithc facility or during off site facility activities 06 Suspected AbuseJNegIcot (The following steps must be completed if allegations are made) Verbal noti?cation in Hill Crest Risk Mann or it local DHR 2. out Child Abuse No ect art to our. Allegations of Sexual Familiarity (Sexual Familiarity includes but is not limited to sexual intro-course with a client; deviant sexual intercourse, or contact; and any form of sexual contact) A Employee to client 3. Client to client I flat? in Reporting Staff Signott?neldate lirondop Stockton. lounge Supervisor signaturefdat 12? Faxed to State DHR Of?ce 1-334-353-2693 on to] l3 ?5 by (detcltime) arson faxing port) Revie 5/11 000222 anorP HILL GROUP HD . . ?0 Hill CrestII-Iigdon Hill 24 Hour Occurrence Notlce 0/9 3 Revenue: - no: 1 ?00 Occurrence Time/Date: 1011606 9:35;! Occurrence Location: Ewan ?it! Home Verbal immediate noti?catirm must he provided within 24 hours after the occurrence or the ?rst wort: my fattening the occurrence. whichever is sooner. A from Higdnn Hill must verbally conlect Rochelle Sharp. ngdott Hill A?i?l?li Director Of 1110 '90va Hem Supervise: IF the takes piece on the weekend ALONG WITH. local admitting county DHR AND Gloria (De?ne) Hollow. State Department nFHumen Resources. O?ce of Licenetne 1-334-242-8171 In addition. Wanda Jordan. Hill Crux Risk Manager must be noti?ed as the program must submit a report to State DER. Of?ce nfLicensure within 5 days of the occurrence. Higdon Hill Program Director noti?ed on lth?tli'lii (it El?n by ??ndnn 51955923 (dato'dlne) Type of noti?cation provided (circle applicable): Telghone mugging, telephone voic email message. faxed occurrence notice House Supervisor J?Mm?H?Aoti?cd on by (1-1.5. name) (sta?? unmeltitie) Type of noti?cation provided (circle applicable): telephone voicemai] message, faxed occurrence notice Mauls.? County alter how's noti?ed on by Sm- Coo (dateJtime) (See attached phone list for admitting county alter-hows contact number) Type of noti?cation provided (circle applicable): Telephone conversation. telephone message. faxed occurrence notice Name of Alter-hours worker that responded to the occurrence Name not mrded date/time @6116 (a 9:303 Response from worker covering the call: State DHR. Gloria Holloway noti?ed on ?t 13:31.: by Rochelle Emma: Diregtgr (doteitimc) (staff nomet'title) Type of noti?cation provided (circle applicable): Telephone conversation telephone voicemnil message. Approved family members noti?ed: Yes No Nemeluelationship of Person noti?ed Noti?ed on by (datef?mc) Type of noti?cation provided (circle applicable): Telephone conversation, telephone voicernnil message, faxed occurrence notice ?Please list the County called and contact number called Please select the following: . ill Client Injury?A11 injuries requiring medical for any client at the facility or while participating in elf-site activities SeLfIndn-y Accident Other 02 Client ?lance?any illness at the facility or while participating in off-site facility activities which required professional medical con?uent. 03 Emma Please note, i?'wheu client rettnned to Yes No Date ofreturn ltiil'mtl r30- 04 Suicidal [client made an attempt to cause harm to seifand received medical treatment) 05 Death (Any death occurring at the facility or during o??site theiliry activities 06 Suspected Abucei'Neglect (The following steps must he completed if allegations are made) 1. Verbal noti?cation to Hill Crest Risk Menu 87. local DHR of?ceiwnrker. 2. CAN Child Abuse Ne ct on to DHR 0? Allegations of Sexual Familiarity (Sexual Familiarity includes but is not limited to 5mm intercom with a client; deviant sexual Intercourse, or contact; and my form of some] contact) A. to client Client to client {13 Other: {1 .I Reporting Staff Signatmeldate Brandon Stockton Supmisor signerureim? . to Stat DHR Of?ce 1-334-353-2693 on it) ?1'74 by PG F316 (datcftintef I. (Person feuin report) Rev-l3 5/11 000223 OCT-17-EE316 @1 18F FROM: HIGDUN HILL GROUP HU 2858384849 TO: 13343538693247?! P. 1 CU Hill Cresunigdon ran 24 Hour Occurrence Notice a a: 1 Commence TimelDate: than!? [5'1 9:533 Occtn'rcnce Location: Higdon ?ll! Home Vgrbal Noti?cation Immediate noti?cation must be provided within 34 hours after the occurrence or the ?rst work day following the common. whichever is sooner. A representative from Higdort Hill must verbally contact Rochelle Sharp, Higdon Hill Assistant Director or the covering House Supervisor the omm-rencc takes place on the weekend ALONG WITH, local athnirting county DHR AND Gloria (Doric-o) Holloway. State of Human Resources. O??ice of Licensme 1-3 34442-3117. In addition. Wanda Jordan, Hill Crest Risk Manager must be noti?ed at the program must submit a report to State DHR. Of?ce of Licensurc within 5 days of the occurrence. Higdon Hill Program Director noti?ed on 9:33;; by Brandon 55953129 (dateltime) (stall nmdti?e) Type of noti?cation provided (circle applicable): Telthonc momma, telephone voicemail message, faxed occurrence notice Home Supervisor Along; 11mg, RH noti?ed on by (RS. name) Malamute) (stalf Type of noti?cation provided (circle applicable): Telephone compliant, telephone voicemnil message. faxed occurrence notice Gully County DHR otter hours noti?ed on goo?ng ?g by S: r- (datchime) (staff namcltitlc) (See attached phone list for admitting county after-hours contact number) Type of noti?cation provided (circle applicable): Telephone conversation. telephone voicemai! message, faxed commence notice Name of Aim-hours worker that responded to the occtn-rence Name not recorded dalel?mc 10116116 (53 9:399 Response from worker covering the call: State DHR, Gloria Holloway noti?ed on yoga by Rochelle Shara-Mubarak Program Directolg (datoftime) (staff namcftitlc) Type of noti?cation provided (circle applicable): Telephone conversation. telephone voicemail message. Wang's; Approved family members noti?ed: Yes it No Namclrelationship of Person noti?ed Noti?ed on by (date/time) (staff namcftitlc) Type of noti?cation provided (circle applicable): Telephone conversation, telephone voicemail message, faxed occurrence notice "Wiener: list the County called and contact number called talent the following: 01 Client Injury?All injtn-ica requiring medical treatment for any client at the facility or while participatimg in oil-site activities Self Injury Accident Other 02 Client lunatic-any illness occurring, at the facility or while participating in off?cite facility activities which required professional medical moment. 03 Rune Please note. ithn client rounded to to Yes No Data oft-atom llh'l?l'?ti 2:31}: 0-1 Suicidal (client made an attempt to capacitor-m to aolfand received professional medical treatment} 95 Death (Any dumb occurring at the facility or during o??citc facility arm'vitios 06 Suspected ('I?hc following stops must he completed ifallcgations are made} 1. Verbal noti?cation to Hill Crest Risk Manager local DI-IR of?ce/worker. 2. C.A.N (Child Abuse Neglect) report to DER OT Allegations of Sexual Familiarity (Sexual Familiarity includes but is not limited to sexual intercourse with a client; deviant sexual intercourse, or contact; and any form of coronal contact) A. Employee to clicnt B. Client to client 08 Other: 1 Reporting Staff Signature/date Brandon Stockton. [0116115 Supervisor aisnaturdda Faxed to State DHR Of?ce 1?334-353-2693 on tempo 13:45 by (date-Mme) 000224 DCT-EE-EIZIS 18: 51P FROM: HIGDUN HILL GROUP 8258384849 TU: 13343326932479 P. 1 810 Hill CrestiHigdon Hill 24 Hour Occurrence Notice 3 Resident Name: - Age: - f/G Occurrence Time/Date: l??S/lg 1! :20a Occurrence Location: ?igdon Hill anp going Verbal Notification Immediate noti?cation must he provided within 24 hours after the occurrence or the ?rst work day following the ocean-nee. whichever is sooner. A from [ligand Hill must verbally contact Rochelle Sharp, Higdon Hill Assistant Director or the covering Home Sttpervisor IF the occurrence talrea place on the weekend AMONG WITH, local admitting county mm AND Gloria (Dorian) Holloway, State Depot-intern of Human Renown, Of?ce ofLinenaure 1-334-242-3117. In addition, Wanda Jordan, Hill Crest Risk Manager must be noti?ed es the program must submit a report to State DER. Dt?ce nfLicenstn'e within 5 days of the ocemrence. Higdon Hill Program Director noti?ed on 1005!] 1 I 22511 by i it new (datcitirnc) (stuff namo'litlc) Type ofnoti?cation provided (circle applicable): kiwi: commotion. telephone voieemail message, faxed occmrence notice House Supervisor noti?ed on NM by (RS. nonie) (datcftime) (sto?nameititlc) Type of noti?cation provided (circle applicable): Telephone conversation, telephone voicemail message, faxed occurrence notice Mobile County or alter hours noti?ed on 1012916 @11 :39- by Sarah Eeeragn, Emmi C99 rdlnator (date/time) (sta?' name/title) (See attached phone list for admitting county alter-home contact number) Type of noti?cation provided (circle applicable): Telephone conversation, telephone voiccmail message, faxed occurrence notice Name of Alter-hours worker that responded to the occurrence NIA date/time Response from worker covering the call: State DER. Gloria Holloway noti?ed on 1006(16 13:23 by Rochelle ShaggMumgm [marlin Director (detcltime) (staff nameftitlc) Type of noti?cation provided (circle applicable): Telephone conversation. telephone voieemail message, WM Approved family members noti?ed: Yea No limo/relationship of Person noti?ed Noti?ed on by (dateitimc) (ata?fnameltitle) Type of noti?cation provided {circle applicable): Telephone conversation, telephone voicemail message. faxed occurrence notice "*le list the County called and contact called Please select the following: ill Client Injury-Al] injuries requiring medical treatment for any client at the facility or nitilc participating in trill-site nedvitlca Accident Other _02 Client Illness-any illncaa occtn-ring at the facility or while participating in off-site facility activities which required professional medical treatment. 03 Rmaway Please note, itlwhen client renamed to program Yea No Date of return 04 Suicidal (client made an attempt to cause harm to self and received professional medical moment) 05 Death (My death newt-ring at the facility or during o??aite facility activities 06 Suspected AbusclNeglect (The following steps must be completed ii'allegations are made) I. Verbal noti?cation to Hill Crest Risk Manager local DHR office/worker. 2. C.A.N (Child Abuse Neglect) report to DHR __tl7 Allegations ot?Scxual Familiarity (Sexual Familiarity includes but is not limited to sexual intercourse with a client: deviant sexual intercom, or contact; and any form of sexual contact) A. Employee to client B. Client to client '03 Elmer: i 1 Reporting Staff _Rochelle Sharp-Marhury Mind/l6 Supervisor ainnaturcfdo?, ZML Faxed to State DHR Office 1-334-353-2693 on 1036!] 3:23 by (Person faxing report) Revised Sill 000225 SHEEP HILL GROUP HU 2253384849 1 8?0 0 Hill Crest/Higdon Hill 24 Hour Occurrence Notice /03 mamm- in Occurrence Time/Date: 1115:5116 11:20:: Occurrence location: Grou orne Verb otll'r ation Immediate noti?cation must be provided within 24 hours after the oecmrenca or the that work day following the commune. whichever is sooner. A representatitre lion: Higdon Hill most verbally contact Rochelle Sharp, Higdon Hill assistant Director or the covering House Supervisor IF the occurrence takes place on the weekend ALONG WITH. local admitting county Dl-lR AND Gloria (Derico) Holloway. State Deparuncnt of Human Resources, Of?ce of Licensm In addition, Wanda Jordan, ilill Crest Risk Manager must be noti?ed as the program must submit a report to State DHR. Ollie: of Licensure within 5 days of the occurrence. Higdon Hill Program Director noti?ed on 1. Ln. on 13:39. by _Dn site during occurrence (dateftime) (staff nameltitle) Type of noti?cation provided (circle applicable): W, telephone voicernail message. faxed occurrence notice House Supervisor noti?ed on by (ES. name} (datct'timc) (staff namcttitle) Type of noti?cation provided (circle applicable): fljegphonc conversation, telephone voicemail message, faxed commence notice gunman County DHR 0R a?er hours noti?ed on mug by Capt-gmator (dateitirnc) (staff nnmeltitie) (See attached phone list for admitting county after?hours contact number} Type ofnoti?cation provided (oh-ole applicable): Telephone conversation, telephone voieernail message. faxed occurrence notice Name of After-hours worker that responded to the occurrence date/time Recponse ?'om worker covering the call: State DHR. Gloria Holloway noti?ed on defld 33:32]! by Rochelle Sher Mari: to treat (date/time) (ataft'namc/titlc) Type ofnoti?cation provided (circle applicable): Telephone conversation, telephone voicemail message. WW Approved family members noti?ed: Yes No Namelrelationship of Person noti?ed Noti?ed on by (dateftimo) (staff nameftitle) Type of noti?cation provided (circle applicable): Telephone conversation, telephone voicemail message. faxed occurrence notice ?Please list the County called and contact number called Please select the following: . . . 01 Client Injury-All injuries requiring medical treatment for any client at the facility or while participating, in off-site activities Snelflujur'jr Accident Other 02 Client [linear-any illness occurring at the facility or while participating in elf-rite facility activities which required professional medical money. 03 Runway Please note, iilwlien client returned to program Yes No Date of tattoo I 04 Suicidal (client made an attempt to cause harm to self and received professional medical treatment) 05 Death {Any death occurring at the facility or during offsite facility activities 05 Suspected ('I?he steps must he completed ifallcgations are made) Verbal noti?cation to Hill Crest Risk Manager 8.: local DHR oilieo'worlrer. 2. CJLN (Child Abuse Neglect! report to DEER d?l?xllegations of Sexual Familiarity (Sexual Familiarity includes but is not limited to sexual intercom: with a client: deviant sexual ton-mouse, or contact; and any form of sexual contact) A. Employee to client B. Client to client 03 Other: Reporting StaffSignnture/dute Rochelle . I??dno Supervisor 1-334-353-2693 on 10%? (El 13:31 by Faxed to State DHR Of?ce {Pusan Revised Sill (datettirne) 000226 o1:4oP HILL GROUP H0 23583842149 T0:13343533693e479 P.1 . Hill Crest/Higdon H0124 Hour Occurrence Notice '7 ResidentName: Age: Occurrence TimeJDate: 5:35;) Occmrence Location: Hill Gropp ?ame Verbal Notilqugn immediate noti?cation must he provided within 24 hours alter the occurrence or the ?rst work day following the commence, whichever is sooner. A representative ?-om Higdon Hill verbally contact Rochelle Sharp. Higdon Hill Assistant Director or the covering House Supervisor IF the enamel: takes place on the neck-end ALONG WITH, local county DHR AND Gloria (De?ne) Holloway. State Department ofHurnen Resources. Union of Licensure 1-334-242-8171. in addition. Wanda .l?cn'dan. Hill Crest Risk Manager must be noti?ed as the program must submit a report to State DI-IR, Ot?oe of Licensm'e Within 5 days ofthe occurrence. Higdon Hill Asst. Director noti?ed on 12126116 6:00p by Hazel Mm_n_hv. MET (dateftlme) (staff nemeltitle) Type of noti?cation provided (circle applicable): Telephone conversation, telephone message, faxed notice Home Supervisor _Sylvia Vinson, RN noti?ed on 12mm {5332 by 1 (HS. name) (dateftime) (staff nnmeJtitle) Type of notification provided (circle applicable): Wat-Em, telephone voicemeil message, faxed occurrence notice _Walkcr_ County a?er hours noti?ed on 1 by MW (date/time) (staff nameltitle) (See attached phone list for admitting county utter-hours contact mnnber) Type of noti?cation provided (circle applicable): Telephone conversation. telephone voicemail message. faxed occur-once notice Name of Alter-hours worker that responded to the occurrence Eocene Foster deter'timel??il? 309 St 1:25 Response from worker covering the cell: State DHR, Gloria Holloway noti?ed on 12127116 I by Rochelle Sh (date/time) (staff namea?title) Type of noti?cation provided {circle applicable): Telephone conversation, telephone voicemail message, WM Approved family members noti?ed: Yes No Norrie/relationship of Person noti?ed Noti?ed on by (datel?me) (Sta??natneltitle) Type of noti?cation provided (circle applicable): Ielgphone contrasting, telephone voicemaii message, faxed occurrence notice ?Please list the County called and contact number called Please select the follot?ggt _01 Client lnjm-y-All injtn-iea requiring medical 501' any client at the facility or while participating in off-site activities Accident Other __02 Client Illness-any illness poem-ring at the facility or while participating in elf-site facility activities which required rnot?essionsl medical treatment. 03 Runaway Please note. ltl'when client returned to program it Yes No Date of return 04 Suicide] (client made no attempt to cause harm to received pm?ssionnl medical treatment) 05 Death (Any death occurring at the facility or duringofl' site facility activities 06 Suspected AbuseINcglect (The following steps must be completed ii?nllegstions are mode) 1. Verbal noti?cation to Hill Crest Risk Marlow local DHR otlicefworitcr. 2. C.A.N (Child Abuse d: Neglect) report to DER 0? Allegations of Emmi Familiarity (Sexual Familiarity includes but is not limited to sexual intercourse a client; deviant sexual intereOurse, or contact; and any form of serum] contact) A. Employee to client B. Client to client or Other: /717 Reporting endowment; mm Supervisor eigoenndda Faxed to State DEIR Of?ce 1-334-353-2693 on [1.11 . it, a, Inc?- by (dateltime) - 000227 DEC-E7-EIIE. omen: HILL snoop Ho 22153384-49 y/ZU/filus34353escse4ra P.1 Hill Crest/Higdon Hill 24 Hour Occurrence Notice Resident Name: Age: Occurrence TirneJDatc: razors 5:45o_ Occurrence Location: 111'ng Hill my}; Home Verbal Eg??ention Immediate noti?cation must be provi?d within 24 hours after the occurrence or the ?rst work day following the occurrence, whichever is sooner. A representative from Higdon Hill must vcrhelly contact Rochelle Sharp. Higdon Hill Assistant Director or the covering Home Supervisor IF the occurrence taken place on the weekend ALONG WITH. local admitting county DHR AND Gloria (Derico) Holloway. State Department othrman Resources, Of?ce of Licensurc 1-334-242-8177. In addition. Wanda Jordan. Hill Crest Risk Mennger mustbc noti?ed as the promo: must submit a report to State DHR, Of?ce of within 5 days of the occurrence. Higdon Hill Asst. Director noti?edon more to 6:00]: by (daldtim?) (sta?'nameftitle) Type of noti?cation provided (circle applicable): Telephone conversation, telephone voic email message, faxed occln'rence notice House Supervisor _Sylvia Vinson, RN noti?ed on l?i 6:0llc by (HS. name) (dateltimc) (stn?' name/title) Type of noti?cation provided (circle applicable): Won, telephone voioernei] message, faxed notice _Itusse11 County Dim alter hours noti?ed on more or 6:301: WW (date/time) (staff narncih'tle) (Sec attached phone list for admitting county alter-how's contact number) Type ol'nnti?cetion provided (circle applicable): Telephone conversation, telephone voicernail message. footed notice Name of Alter-hours worker that responded to the occurrence _Mianna datcftimol agate 7: ion pronsc ?-orn worker covering the call: his Kel communloa that it had doctnnerned their: EME- State DHR1 Gloria Holloway noti?edon 16 12:59:) by Ron elle Sh - orb to (dutch il1m) (sta?' name/title) Type of noti?cation provided (circle applicable): Telephone conversation, telephone Voicenrail message. MW Approved family members noti?ed: Yes No Namelr'elntionship of Person noti?ed "Mother Noti?ed on IMGHQ 6:09;; by (doleltimc) (staff name/title) Type of noti?cation provided (circle applicable): Iglghone convc?ulion, telephone voice-mail message, faxed occrn'rence notice ?*Please list the County called and contact number called Please select the following: 0] Client Injury-All injuries requiring medical ueuhnent For any client at the facility or while participating in DEE-cite activities Self Injury Accident Other 02 Client Illness-ow illness occurring at the facility or while participating in of?nite facility activities which required professional medical continent. 03 Runaway Please note, i?lwhen client returned to program Yer Date of room 04 Suicidal (glint! made an attempt to came harm to reifend received profusionnl medical treatment) 05 Death An death occorrin at the facility or during_l?fsite facility annuities moo Suspected Ahmo?hleglect (The following steps must he completed if allegenons are made) i. Verbal noti?cation to Hill Crest Risk mag .it local DHR nti'reehrorlcer. 2. CA gChild Abuse a?egl calm to DER or Allegations of Sexual Familiarity (Sexual Familiarity includes but' or not limited to sexual irrtercnrune with a client; deviant sexual intercourse, or contact; and any form of sexual contact) A. Employee to client 13. Client to client 03 Other: I an: in lr Reporting Sm?Sigldeq?cL-IW mm W: ill Supervisor simulurcfdate Faxedro on ham-[la a. lice-o by (date/tune) Revinc 5/11 000228 Derico, Gloria From: Sent: To: Subject: Attachments: Follow Up Flag: Flag Status: Wanda Jordan RN Asst. Director of Nursing Jordan, Wanda Friday, April 01, 2016 2:57 PM psy21report@adap.ua.edu; 21 Serious Reports.15.16. MCD 21 Serious Reports.15.16. MCD.docx Follow up Flagged Hill Crest Behavioral Health Services 6869 Fifth Avenue South Birmingham, Alabama 35212 Of?ce 205-838-2076 Fax 205-776-6463 UHS of Delaware, lnc. Con?dentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review, use, disclosure or distribution of this information is prohibited, and may be punishable by law. If this was sent to you in error, please notify the sender by reply e-mail and destroy all copies of the original message. 000229 4/15/10 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DI-IR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 C. F.R. 6483.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident's record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 4045627435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: March 28 2016 5 Report of Serious Occurrence has been placed in resident record March 31 2016 Centers for Medicare and Medicaid Services Regional Of?ce Alabama Disabilities Alabama Medicaid Agency Advocacy Program Alabama Department of Human Resources Ms. Susan Ward, Dir. Of?ce of ADAP Executive Director Ms. Jan Sticka,, Program Resource University of Alabama Manager Mental Health 8. Gordon Persons Building Box 870395 501 Dexter Avenue I I th 50 Ripley Street Tuscaloosa, AL 35487- Montgomery, Alabama 36104 PO Box 304000 0395 and fax to one Montgomery, AL 36130 FAX 404-562-7435 334-353-4151 334-353-2309 (fax) 1 @321regort@medicaid.aIabamagov 334-242-1653 205-343-4928 psyZiregort@dhr.aiabama.gov Page 1 of 4 000230 4/15/10 Section 1. Facility Information: 21 Facility Program name: Hill Crest Behavioral Health Rise Unit . . Street Address/Clty/le 6869 5 Avenue South Birmingham, Alabama 35212 Telephone/Fax 205r838?20?6/ 776-5463 fax Name/Title of person completing report: Wanda lordan RN Director of Risk Management Section 2. Resident Information: Date of this report March 31. 2016 Date/1' ime of serious occurrence: March 28. 2016f7:10 PM .Resident full Name-?Resident date of birth: Gender: Female Dx: Conduct Disorder I Description of Incident: pate/Time of incident: Was the resident in a restraintfseclusion at time of incident? ng resident during her hygiene time, he knocked on the door received no 1 response from he called for assistance from a female staff. When the staff opened the door, she found in the shower and noticed blood on resident?s wrists and neck. A Rapid Response was called. unit RN provided first aid for her injuries. When resident was questioned about the incident, the resident stated she had removed a screw from her room?s door, hid it in her bra and used it harm herself. Her physician was notified of the incident and placed her on one to one observation, . she placed in scrubs for her safety placed on suicide and safety precaution. The staff searched her room for any items that she could use to harm herself and removed them. Per her therapist, the resident stated she was tired of being at Hill Crest". Her therapist will continue to meet with her daily to discuss her behavior and any issues she may have. gate/Time of incident: March 28. 2016/7310 PM 1 Was the resident in a restraint/seclusion at time of incident? NO While staff 000231 4/15/10 Section 5. Report of a Death of Resident (The death of a resident, regardless of circumstances or causation, MUST be reported to all agencies listed above, including CMS Regional Office. Please submit Death Reporting Worksheet ., to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation, including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No If yes, check type: Restraint Seclusion Section 6. Definitions Raceof resident is classified as W(White) B(B1ack) H(Hispanic) 0(Other, including Native Amer. Asian) Restminrmeans a ?personal restraint? a ?mechanical restraint? or udrug used as a restraint.? Personal restraint means the application of physical force without the use of any device, for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to cairn or comfort resident, or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that hefshe cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that (1) is administered to manage a resident?s behavior in a Way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. Sedosion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious 11m means any signi?cant impairment of the physiCal condition of the resident requiring medical treatment by a licensed medical doctor, osteopath. podiatrist, dentist, physician's assistant, or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care ho5pita1. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include, but are not limited to: burns, lacerations requiring sutures, bone fracture, substantial hematomas. internal organ injuries, head injuries and sprains/suspected bone injury ifX?ray is ordered. Suicide-Attempt is an act that demonstrates some minimal non?zero intent to die as a result of the act.l This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident, even if no harm actually resulted from the act.I The act under this definition includes unplernenting any steps to carry out a plan (Le. putting a rope around one?s neck): A suicide attempt also includes attentionrsceking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting 1 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development, Inc. in collaboration with American Association of Suicidology; Revised October 2008, citing ?Columbia Suicide-Severity Rating, Scale developed by Posner, Brent, D. Lucas Gould, Stanley, Brown, Fisher, Zelamy. Burke, Oquendo. Mann, 1 Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development, Inc. in collaboration with American Association of Suicidologl? Revised October 2008. Page 3 of 4 000232 4/15/10 injury. Therefore, even if no physical injury occurs during a suicide attempt, it should still be reported as a serious occurrence. per the federal reporting regulations. Page 4 of 4 000233 Derico, Gloria From: Jordan, Wanda Sent: Friday, April 01, 2016 9:30 PM To: psy21report@adap.ua.edu Subject: 21 Serious Reports.15.16. MCD Attachments: 21 Serious Reports.15.16. MCD.docx Wanda Jordan RN Asst. Director of Nursing Hill Crest Behavioral Health Services 6869 Fi?h Avenue South Birmingham, Alabama 35212 Of?ce 205-838?2076 Fax 205?776-6463 UHS of Delaware, Inc. Con?dentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review, use, disclosure or distribution of this information is prohibited, and may be punishable by law. If this was sent to you in error, please notify the sender by reply e?mail and destroy all copies of the original message. 000234 4/15/10 2i Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 CFR. 5483.352, or suicide attempt by a resident. See Section 6 for de?nitions. Please print or type the requested information below. For each serious occurrence. scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional of?ce may be submitted via fax at 40425624435. Document in the resident's record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: March 30 2016 Report of Serious Occurrence has been placed in resident record April I, 2016 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Centerslfor Medicare and Human Resources Advocacy Program Medicaid Servlces Regional Office Ms. Susan Ward, Dir. Office of ADAP Executive Director Ms. Jan Sticka,. Program Resource University of Alabama Manager Mental Health S. Gordon Persons Building Box 870395 501 Dexter Avenue 1 50 Ripley Street Tuscaloosa, AL 35487? Montgomery, Alabama 36104 PO Box 304000 0395 and fax to CMS Montgomery, AL 36130 334-242-1553 20 5-343-4923 334-353-4151 FAX 404-582-7435 334-353-2309 (fax) osv21reporttdidhralabamanov "390 rt@adap.ua.edu gsv21report?megicgidalabamauov Page 1 of 4 000235 Section 1. Facility Information: 21 Facility/ Program name: Hill Crest Behavioral Health Bessemer Group Home Street Address/City/Zip 6869 5?3? Avenue South Birmingham, Alabama 35212 Telephone/Fax 205-838'20762? 7766463 fax Name/'1' itle of person completing report: Wanda lordan RN Director of Risk Management Section 2. Resident Information: Date of this report April 11 2016 Date/Time of serious occurrence: March 30, PM .Resident full Name-__Resident date of birth: ame Address Ph dian: Race: Gender: Male Dar: Conduct Disorder Description of Incident: Date/Time of incident: Was the resident in a restraint/seclusion at time of incident? Section 4. Report of a suicide Attempt by a Resident: ?physician sent him to a local ER for evaluation/treatment of an overdose of OTC cough medication. The evening of the incident, staff noticed Rashid was acting strange, when questioned he . admitted to takin the pills. In the ER he received a charcoalfsorbitol treatment and was admitted for observation. as discharged from the Medical Center the following morning and was re? I admitted back at Bessemer group home in stable condition. Per the reason he took the medication he wanted to get high". Date/Time of incident: March 30. 2016! 10:00 PM Was the resident in a restraintZseclusion at time of incident? NO 000236 4ll5/10 Section 5. Report of a Death of Resident (The death of a resident, regardless of circumstances or causation, MUST be reported to all agencies listed above, including CMS Regional Office. Please submit Death Reporting Worksheet to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation, including incident reports and medical reports): DatefTime of death Was the resident in restraints or seclusion at time of death? Yes If yes, check type: Restraint Seclusion Section 6. Definitions Race of resident is classi?ed as WCW'hite) B(Blacl<) H(Hispanic) 0(Other, including Native Amer, Asian) Restraint means a ?personal restraint? a ?mechanical restraint" or ?drug used as a restraint.? Personal restraint means the application of physical force without the use of any device, for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident, or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that he/she cannot easily neurons that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that (1) is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident?s freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. Sedusr?on means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious In?? rgmeans any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor, osteopath, podiatrist. dentist, physician's assistant, or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor ?rst aid. Examples of serious injuries include but are not limited to: bums, lacerations requiring sutures, bone fracture, substantial hemaromas, internal organ injuries, head injuries and sprains/suspected bone injury ifX-?ray is ordered. Suicide Attempt is an act that demonstrates some minimal non'zero intent to die as a result of the act.l This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident, even if no harm actually resulted from the act.2 The act under this definition includes implementing any steps to carry out a plan (Le. putting a rope staund one?s neck).3 A suicide attempt also includes attentioneseeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event, despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development, Inc. in collaboration with American Association of Suicidology; Revised October 2008, citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner, Brent, Lucas 0; Gould, Stanley, Brown, Fisher, chazny, Burke, Oquendo, Mann, 2 Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals: Suicide Prevention Resource Center, Education Development, Inc. in collaboration with American Association of Suicidology; Revised October 2008. Page 3 of 4 000237 4/15/10 injury. Therefore, even if no physical injury occurs during a suicide attempt, it should still be reported as a serious occurrence, per the federal reporting regulations. Page 4 of 4 000238 unmet Derico, Gloria JAMS alarm/am mergers. him A. t/ From: Jordan, Wanda gm Sent: Monday. January 06, 2014 5:17 PM To: psyereport@adap.ua.edu; Subject: 21 Serious Reports.13. MCD.docx Attachments: 21 Serious Reports.13. MCD.docx PRIVILEGED AND CONFIDENTIAL PATIENT SAFETY WORK PRODUCT Wanda Jordan, R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham, Alabama 35212 205-838-4034 (phone) 205-838-4024 (fax neeom UHS of Delaware, Inc. Con?dentiality Notice: This c-mail message. including any attachments, is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review. use, disclosure or distribution of this information is prohibited. and may be punishable by law. Il?this was sent to you in error, please notify the sender by reply e-mail and destroy all copies ol?the original message. I 000001 4/l5/i0 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This remt must be submitted no later than the close of business the next business dav after a serious occurrence. Serious occurrences under the Act that must be reported include a resident's death (for any reason), serious injury (for any reason) to a resident as defined in 42 GER. ?483.352, or suicide attempt by a resident. See Section 6 for de?nitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of this form to each of the three agencies identified in the boxes below and enter onLcopv in the resident's record. In addition, please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 404562-7435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: December 28, 2013 5 Report of Serious Occurrence has been placed in resident record [anuary 6, 2014 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Centers for Medicare and Human Resources Advocacy Program Medlcaid Serwces Regional Office Ms. Susan Ward, Dir. Of?ce of . ADAP Executive Director Ms. Karen Smith. Program Resource University of Alabama Manager Mental Health S. Gordon Persons Building Box 870395 501 DexterAvenue 50 Ripley Street Tuscaloosa. AL 35487-0395 Montgomery. Alabama 36104 PO BOX 304000 and fax to cats Montgomery, AL 36130 334-242-1653 205-348-4928 334-353-4945 FAX 404-562-7435 21r hr.l 95x21 ragcgt?adagmagdu Page I all 000002 Section 1. Facility Information: 21 Facility I Program name: Hill Crest Behavioral Health. Unit: Phoenix Street Address/City/Zip 6869 Avenue South Birm?gham. Alabama 35212 Telephone/Fax 205e83B?4034 83840424 fax Name/Title of person completing report: Wanda iordan RN Director of Risk Management Section 2. Resident Information: Date of this report anuarg 06, 2014 Date/Time of serious occurrence: December 28.2013f7z25 PM Resident Full name- Resident date of birth: Resident?s race: [Xi Resident gender: Male (X) Female( Disability/diagnosis: Impulse Control Section 3. Report of a Serious Injury to a Resident: Was the resident in restraints or seclusion at time of serious iniurv? Yes No 1 If yes,check me: Restraint Seclusion_[_] .. Section 4. Report of a Suicide Attempt by a Resident. Staff found-in his room with a sock tied around his neck. Staff imwi removed the sock. Upon assessment, no injuries were noted and he did not voice any pain or injury. staff. I want to die. don?t want to live." He began yelling, screaming that he wanted to leave the unit. continued to escalate and refused redirection from stall. A PRN medication was given to help him to calm down. received the medication willingly. Stal' all items from his room that he could use to harm himself. His physician was notified of the incident. was placed on a one to one obscuration while awake and placed on suicide precautions. He was placed in paper scrubs since he tried to use clothing to harm himself. 000003 4/15/10 ., Section 5. Report of a Death of Resident (The death of a resident, regardless of circumstances or causation. MUST be reported to all agencies listed above. including CMS Regional Office. Please submit Death Reporting Worksheet .. to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Dateffime of death Was the resident in restraints or seclusion at time of death? Yes No If yes. check type: Restraint Seclusion Section 6. Definitions Race of resident is classified as W(White) B(Blaci<) H(Hispanic) 0(Other. including Native Amen. Asian) Restraint means a ?personal restraint" a ?mechanical restraint" or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident's hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that he/she can not easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement; and (3) is nor a standard treatment for the resident's medical or condition. Seclusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious thing? means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the trculmt?nl received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but at: not limited to: burns. lacerations requiring sutures, bone fracture. substantial hematomas. internal organ injuries. head injuries and sprains/suspected bone injury ivaray is ordered. Suicide Attempt is an act that demonstrates some minimal nonlzero intent to die as a result of the act.l This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.2 The act under this definition includes implementing any steps to carryout a plan (it. putting a rope around one?s neck).? A suicide attempt also includes attention'sceking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting injury. Therefore. even if no physical injury occurs during a suicide attempt. it should still be reported as a bL?i?InUb occurrence. per the federal reporting regulations. Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development, inc. in collaboration with American Association ofSuicidoiogy; Revised October 2008, citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Former, Brent. Dc, Lucas C.: Gould. Ms. Stanley. Brown. Fisher. Zelazny, J.: Burke. A4 Oquendo. M.: Mann. Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association of Suicidology; Revised October 2008. Page .3 of! 000004 I (5 2445.5 a? HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-638-4034 FAX 205-838-4024 FACSIMILB TRANSMITTAL SHEET FROM: Gloria De?xicu Holloway Wanda .Iardm Ml. comnm Dan.- Stat: ofAlabama 1-16-14 FAX NUMBER: Tom. no. or mass INCLUDING 334-353?2693 2 PHONE NUMIFK: 334-242-8177 To The information maniac-d in thin mating: in legally privilqed and mun-1 Morgana?, la inthon-Jyfor nu: o?hn {unlit-Mm! or mil} umd than. ?lh: mule! oilhiu mung: not than you In: hqaby no??ud that any ust. Hannah-dun. of 11m Emu": it [Kieth whibiu?. Hm hm mind. um in man plane 1:0de the 6069 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000005 -- 4h?-i-I. nu Crest Behavioral Health Services 6359 Avenue South Birmingham, Alabama 35211 Date of Report: Datefl'lme of WW Group Home: ?g?emar ?gmg Report Received: mamber 2013 1.Resident of Nameoquardian:? Gender: Male magnesium 2. Resldent Name:? Date of Birth: Name of Guardian:? Race?gsg (Sentienm WW: - and _ms In a verbal escalated to I physical altercation before could separate them. Om the ruldenu were separated. both were assessed for Injuries. received I bloody nose, first aid was provltlud.-rennlued a bloody nose and his left was bruised. ?rst was provided by mu. Our cam mluatad bath residents. no fur?m tm?mnt requlrad fm_ but -was referred to a local emergency room for further lull treatment for his bruised left an. -mturmd from the emergency room the same day. His dlagnosis was; a contusion to hit Itft eye. No further treatment was required.-dnnlad any vlslon problems. an KM wand. la Director Of Risk Management 000006 .1.- Derico, Gloria From: Jordan, Wanda Sent: Wednesday. January 154 2014 2:42 PM To: psyereport@adap.ua.edu; Subject: 21 Serious Reports.13. MCD.docx Attachments: 21 Serious Reports.13. MCD.docx PRIVILEGED AND CONFIDENTIAL PATIENT SAFETY WORK PRODUCT Wanda Jordan, R. N. Director 01' Risk Management 6869 Fifth Avenue South Birmingham, Alabama 35212 205-838-4034 (phone) 205-838-4024 (fax wan-(in. i nrdan uhsi moon] UI-IS of Delaware, lnc. Con?dentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review. use, disclosure or distribution of this information is prohibited, and may be punishable by law. If this was sent to you in error. please notify the sender by reply e-mail and destroy all copies of the original message. This Jedi? 3% limit?! A, D?t?fi" 1 000007 4/15/l0 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources Each 21 facility is required to report any and all serious occurrences to: Alabama's Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR. the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 CFR 3483.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence. sean and email copies of this form to each of the three aggicies identified in the boxes below and enter one copy in the resident's record. in addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 4045624435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted December 21, 2013 3; Report of Serious Occurrence has been placed in resident record january 15. 2014 Alabama Disabilities I Alabama Medicaid Agency Advocacy Program Centers for Medicare and Medicaid Services Regional O?lce Alabama Department of Human Resources Ms. Susan Ward. Dir. Of?ce of ADAP Executive Director Ms. Karen Smith, Program Resource University of Alabama Manager Mental Health 8. Gordon Parsons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa. AL 35487-0395 Montgomery. Alabama 36104 PO BOX 304000 and fax to CMS Montgomery. AL 36130 334-353-4945 FAX 404-582-7435 205-348-4928 334-242-1653 Page I of 3 000008 Section 1. Facility Information: 21 Facility Program name: Hill Crest Behavioral Health. Unit: Rise Street Address/City/Zip 6869 5"h Avenue South Birmingham, Alabama 35212 Telephone/Fax 205838?4034 8384024 fax Name/Title of person completing report: Wanda hardan RN Director Omsk Management Section 2. Resident Information: Date of this report: Ianua? 15 2014 Date/Time of serious occurrence: December PM Resident full name: - . . Namer'Addressi Phone of Giigan: Resident?s race: I 1 Resident gender: Male() Female (X i Disability/diagnosis: Impulse Control Section 3. Report of a Serious Injury to a Resident: Was the resident in restraints or seclusion at time of serious injury? Yeal] No 1' If yes, check type: Restraint Seclusion FF Section 4. Report of a Suicide Attempt by a Resident. _While Staff was doing their observation rounds that evening, they found in her room with camisole strap tied around her neck. Staff immediately cut the strap off. began yelling for the nurse to leave the room. Upon assessment the nurse noted she had not sustained any injuries, no difficulty in talking or breathing. No red marks or broken skin was noted. ?continued to yell and be out of control. The nurse notified her sician of the situation. Order was received to give . her a PRN medication to help her to calm down. ?accepted the medication without a struggle. She was placed on one to one observation for her safety. While she was processing with staff she alleged she had swallowed a small piece of medal. An naray was ordered which indicated no foreign body found. She Stated she had gorten upset with a peer who has" voodoo" and she did not like it. Staff tried to explain there were other ways she could have handled her anger. Ierns that she could possible - use to harm herself were removed from her room. No further problems were noted. 000009 4fl5ll0 Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation. UST be reported to all agencies listed above. including CMS Regional Office. Please submit Death Reporting Worksheet to MS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No if yes. check type: Restraint[ Seclusion[ Section 6. Definitions Raceol resident is classified as W(White) B(Black) H(Hispanic) 0(Other. including Nat ivc Amen. Asian) means a ?personal restraint" a ?mechanical restraint" or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident's hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that he/she cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that (1) is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others: (2) has the temporary effect of restricting the resident's freedom of movement; and (3) is not a standard treatment for the resident's medical or condition. Secfusran means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious [nfurjmeans any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include, but are not limited to: burns. lacerations requiring sutures. bone fracture, substantial hematomas. internal organ injuries. head injuries and sprains/suspected bone injury r' Jimmy is ordered. ,Em'cfde Attempt is an act that demonstrates some minimal nonvzero intent to die as a result of the act.I This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act! The act under this definition includes implementing any steps to carry out .i plan (Le. putting a rope around one?s neck).1 A suicide attempt also includes attentionseeking conduct ill the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the Inuit of a resulting injury. Therefore. even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence. per the federal reporting regulations. Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource CenterI Education Development, inc. in collaboration with American Association of Suicidology; Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner. Brent. Lucas Gould. Ms, Stanley. Brown. Fisher. P.1Zelazny. Burke. Oqueodo. Mann. 2 Attempt De?nition '1 Assessing and Managing Suicide Risk~Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association ol" Suicidoiogy: Revised October 2008. Page 3 of 3 0000 0 .37 v/Wpy-r Derico, Gloria (39/713 {3 From: Jordan, Wanda Sent: Friday. January 31, 2014 5:17 PM To: psyerepon@adap.ua.edu: Subject: incident. 1.24.2014 Attachments: 21 Serious Report5.l4. MCD.docx PRIVILEGED AND CONFIDENTIAL PATIENT SAFETY WORK PRODUCT Wanda Jordan, R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham. Alabama 352 2 205838-4034 (phone) 205-838-4024 (fax wands.iordunf?c??uhsinccom UHS of Delaware, Inc. Con?dentiality Notice: This email message. including any attachments, is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review, use. disclosure or distribution ofthis information is prohibited, and may be punishable by law. It'tl'iis was sent to you in error. please notify the sender by reply e-mail and destroy all copies of the original message. 00001 1 4/35/l0 1: 21 Serious Occurrence Reporting Form This reporting form is to be used by residential rteatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 C.F.R. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 1: 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP). the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any' reason), serious injuor (for any reason) to a resident as defined in 42 CPR. 5483.352. or suicide attonpt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 4045624435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted january 24, 2014 Report of Serious Occurrence has been placed in resident record Ianuary 31. 2011 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Centers for Medlcare and Human Resources Advocacy Program Medicaid Semees Regional Of?ce Ms. Susan Ward, Dir. Of?ce of ADAP Executive Director Ms. Jan Slicka.. Program Resource of Alabama Manager Mental Health 8. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa, AL 35487- Montgomery. Alabama 36104 3:93; :oumvgf?sghe?n PO Box 304000 0395 PETE: and fax to CMS Montgomery. AL 36130 334-242-1553 205-349-4923 334-353-4151 FAX mam-7435 aacasszaos (lax) 2221mm 4{15/l0 Section 1. Facility information: 21 Facility/ Program name: Hill Crest Behavioral Health. Unit: R.is_e Street Address/City/Zip 6869 Avenue South Birmingham Alabama 35212 Telephone/Fax 2053384034 8384024 fax Name/Title of person completing report: Wanda lordan RN Director of Risk Management Section 2. Resident Information: Date of this report anua?y 3i 2% Date/Time of serious occurrence: lanuagy 24. 2014.!' 2:10 PM Resident full name: Name Addres Phone of Guardian: Resident?s race: 3] Resident gender: Ma]e() Female (X Resident?s Disability/diagnosis: Episodic Mood Disorder. Section 3. Report of a Serious Injury to a Resident: In the event of a suicide attempt that results in serious injury, complete BOTH Sections 3 and) DatefTirne of serious iniury or discovery of iniury] Was the resident in restraints or seclusion at time of serious injury? Yes No L) If yes. check type: Restraint Seclusion a Suicide Attempt by a Resident. punching him in the chest, other staff tried to calm her wn but she refused, would not follow any redirections. She had to be placed in a physical restraint for her safety and the safety of other. She was released from the restraint when she became calm. She was escorted to her room. The staff went into 1 the room in order to process with her and found that she had wrapped a tank top around her neck and 5 attempted to strangle herself. Staff immediately removed the tank top. Her breathing was normal, no shortness. was able to speak without any difficulty. No visible injuries were noted. Her physician placed her on suicide precautions and on constant observation. All items that she could use to harm herself from her room and she was placed in paper scrubs for her safety. The nurse notified DHR worker about the inciden who voiced understanding. Date/Time of the incident: lanuary 24. 2014/ 2:10 PM . Was resident in a restraint or seclusion at time of incident? N01 000013 4!lS/l0 Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation MUST be reported to all agencies listed above, including CMS Regional Of?ce Please submit Reporting Worksheet to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of deathll Yes No if yes.check type: Restraint[ Seclusion[ Section 6. Definitions Race of resident is classified as WONhite) B(Black) H(I-iispanic) 0(Othcr. including Native Amen. Asian) ?esrrainrmeans a ?personal restraint" a ?mechanical restraint? or ?drug used as a restraint.? Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident's hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that helshe cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that (I) is adminiStered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement; and (3) is not a standard treatment for the resident's medical or condition. Secfusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious {.11qu means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse pracritioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private of?ce through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor ?rst aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial hemaromas. internal organ injuries. head injurics and sprains/suspected bane injury 1f eray is ordered. Suicide Attemgt' 15 an act that demonstrates some minimal nonvzero intent to die as a result of the act. 1 This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident even if no harm aetually resulted from the act. The act under this definition includes itnplementing any steps to carry out a plan putting a rope around one 's neck) A suicide attempt also includes attention seeking canduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development, Inc. in collaboration with American Association of Suicidology; Revised October 2008. citing ?Columbia Suicide- -Severity Rating Scale (C- SSRS) developed by Posner, Brent. 0.: Lucas Gould. M.: Stanley. H. ?Brown Fisher P4 chamy. Burke. Oqucndo. Mann. J.. 2 http: waw .i?de. -0l-CU-Posner. ppiil936. l2. Suicide Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development. inc. in collaboration with American Association ofSuicidoiogY: Revised October 2008. 3 ?l4 4f15/l0 injury. Therefore, even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence, per the federal reporting regulations. Pelge4of4 0000 5 04/ Derico, Gloria i?fin-Jv. ?fty?) From: Jordan, Wanda Sent: Friday; January 31, 2014 4:53 PM To: p5y21report@adap.ua.edu; Subject: incident 1-26-14 Attachments: 21 Serious Reports.14. MCD.docx PRIVILEGED AND CONFIDENTIAL PATIENT SAFETY WORK PRODUCT Wanda Jordan. R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham, Alabama 35212 205-838-4034 (phone) 205-838-4024 (fax) wandaiordan?tuhsi nee-om UHS of Delaware, inc. Con?dentiality Notice: this e-mait message, including any attachments, is for the sole use of the intended reeipientt?s) and may contain confidential and privileged information. Any unauthorized review. use. disclosure or distribution of this information is prohibited, and may be punishable by law. lfthis was sent to you in error. please notify the sender by reply e-mail and destroy all conies of the original message. 1 00001 6 4/15/10 21 Serious Occurrence Rgporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business dayr after a serious occurreng Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 CPR 6483.352. or suicide camp: by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence. scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident's record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services(CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 404,562,743; Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted Lanuary 28. 2014 5 Report of Serious Occurrence has been placed in resident record anu?y 2014 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Centers for Medicare and Human Resources Advocacy Program Medicaid Services Regional Of?ce Ms. Susan Ward, Dir. Of?ce of ADAP Execuh?ve Director Ms. Jan Sticka,. Program Resource University of Alabama Manager Mental Health S. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa. AL 35487? Montgomery. Alabama 36104 BPglenagsem?onmuglegrtESQF-L?; PO Box 304000 - 0395 and fax to CMS Montgomery. AL 36130 334-242-1653 205-348-4928 334-353-4151 334-353-2309 (fax) 21? '3 ?33 .ua.edu . Page I of 4 00001 7 4/15/[0 Section 1. Facility Information: 21 Facility/ Program name: Hill Crest Behavioral Health. Unit: Rise Street Address/City/Zip 6869 5'h Avenue South Birminaham. Alabama 35212 Telephone/Fax 2056384034 83840241? Name/Title of person completing report: Wanda lordan RN Director oi" Risk Management Section 2. Resident Information: Date of this report: anugy 31 2014 Date/Time of serious occurrence: [anuary 26, 2014f 6:15 PM Resident lull name? NamefAddresl' Resident?s race: 1 W1 Resident gender: Male() 'Female (X - Resident's Disability/diagnosis: Conduct Disorder. Section 3. Report of a Serious Iniury to a Resident: In the event of a suicide attempt that results in serious injury. complete BOTH Sections 3 and) became upset after speaking with her therapist . about her possible discharge an into her room, cursing yelling. threatening staff and she punched the wall with her right fist. Upon assessment, the nurse noted that her right hand was swollen. denied pain. Her physician ordered an array. The x?ray results were received on 14840144 which indicated an acute fifth metacarpal fracture, (Boxer Fracture). A orthopedic appointment was scheduled for later that day at Due to the severe weather, the appointment was cancelled. no other offices were opened. She will be evaluated by the orthopedic on Monday Februa 3, 2014 at 9:00 AM. Resident has denied having any pain to her right hand. The nurse documented DHR worker was notified of the incident and voiced understanding. Dam/Time of serious injury or discovery of iniury) 1464014 6:15 PM Ms the resident in restraints or seclusion at time of serious injury? Yes rug X) If yes, check type: Restraint [l Seclusion 000018 Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation. MUST be reported to all agencies listed above. including CMS Regional Office. Please submit Death Reporting Worksheet to CMS in case of death .. Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No[ if yes. check type: Restraint[ Seclusion[ Section 6. Definitions Raccoi resident is classified as W(White) B(Black) H(l-iispanic) 0(Other. including Native Amen, Asian) Restraint means a ?personal restraint? a ?mechanical restraint" or ?drug used as a restraint.? Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to calm or comfort resident, or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that lie/she cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement; and (3) is nor a standard treatment for the resident's medical or condition. Seclusign means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious lining! means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor ?rst aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial hematomas. internal organ injuries. head injuries and sprains/suspected bont injury levrcy is ordered. gulcide an act that demonstrates some minimal non?zero intent to die as a result of the act.I This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.? The set under this definition includes implementing any steps to carry our a plan (it. putting a rope around one's neck).3 A suicide attempt also includes attentionvseelting conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development, inc. in collaboration with American Association of Suicidology: Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner. 14.; Brent. Lucas C3. Gould. Stanley. 3.: Brown. Fisher. chazny. 1.: Burke. Oquendo. Ms Mann. 1 Attempt De?nition Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association of Suicidology; Revised October 2008. 3 000 4115!?) injury. Therefore. even if no physical injury occurs during a suicide attempt. it should still be reported as a scrious occurrence. per the federal reporting regulations. Pa 0 4 0? 000030 i - 2451? ?ggz?w?w 4% Derico. Gloria From: Jordan, Wanda Sent: Wednesday, February 05, 2014 3:47 PM To: psy21report@adap.ua.edu; Subject: 21 Serious Reports.14. MCD.docx Attachments: 21 Serious Reports.14. MCD.docx PRIVILEGED AND CONFIDENTIAL PATIENT SAFETY WORK PRODUCT Wanda Jordan, R. N. Director of Risk Management 6869 Filth Avenue South Birmingham. Alabama 35212 205-838-4034 (phone) 205-838-4024 (fax ti. UHS ol?Delawarc, lnc. Con?dentiality Notice: This c-mail message, including any attachments, is for the sole use ol?thc rccipicnt(s) and may contain con?dential and privileged information. Any unauthorizcd rcvicw, use. disclosure or distribution of this inl?onnation is prohibited, and may bc punishable by law. ll?this was sent to you in error, please notify the sender by reply c-mail and destroy all copies ol?thc original mcssugc. 000021 4/15/10 21 Serious Occurrence Reporting Fortn- This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 C.F.R. 5 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama's Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason). serious injury (for any reason) to a residentas defined in 42 CPR. 6483.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence. scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 40415624435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include dare: Parent and/or legal guardian has been contacted: February}. 2014 Bi Report of Serious Occurrence has been placed in resident record February 5. 2014 Centers for Medicare and Medicaid Services Regional Of?ce Alabama Disabilities Advocacy Program Alabama Department of Alabama Medicaid Agency Human Resources Ms. Susan Ward. Dir. Of?ce of . ADAP Executive Director - Ms. Jan Sticka,. Program Resource University of Alabama Manager Mental Health 8. Gordon Persons Building Box 570395 501 Dexter Avenue 50 Ripley Street Tuscaloosa, AL 35487- Montgomery. Alabama 36104 PO BOX 304000 and fax to CMS Montgomery, AL 36130 334-353-4151 FAX 404662-7435 334-353-2309 (fax) 205-348-4928 9:12] regomdhulabgmaggy 334-242-1653 4/15/10 .. Section 1. Facility Information: 21 Facility 1* Program name: Hill Crest Behagioral Health. Bessemer Boys Group Home Street Addressz'Citnyip 6869 5?1 Avenue South Birmingham, Alabama 35212 Telephone/Fax 20543384034 8384024 fax Name/Title of person completing report: Wanda Ionian RN Director of Risk Management Section 2. Resident Information: Date of this report February 5, 20M Date/Time of serious occurrence: February 2, PM Resident full name- Resident date of birth: Resi ent's Race: 3 Gender: Male Dir: Mood Disorder the event of a suicide attempt that results in 4 Section 3. on: of a Serious ur to a Resident: In serious injuil complete BOTH Sections 3 and 4) - and were in a verbal altercation which developed into a physical altercation before staff could separate em. on assessment, iniuries were noted as follows and both were sent to a local . emergency room for treatment; - small cut to upper lip and a broken tooth. rec?d 2 sutures to his upper lip and his tooth was evaluated by a dentist on February 3. 2014, the root will be repaired. swoll right hand, xeray revealed a right fifth metacarpal and a left non-displaced fifth i digit fracture. right hand was placed in an ulnangutter splint and his left fifth digit was placed in an aluminum foam splint. has a follow?up ap oi cut with an Orthopedic on Friday February 7, oth residents tolerate eir treatment well. returned to the group later the same night. was taken to tie: at evening because he had used a piece of 0 hit - The . morning of February had a hearing before a judge who returned back to the group - home. No further incidents complications have occurred. Date/Time of incident: February 2, 2014 2? 10:45 PM Was resident in arrestraintfseclusion at time of incident? NO .. Date/Time of the incident; Was resident in a restraint or seclusion at time of incident? 000023 . Section 5. Report of a Death of Resident (The death of a resident, regardless of circumstances or causation. MUST be reported to all agencies listed above. including CMS Regional Office. Please submit Death [grinning Worksheet to MS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation, including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No If yes. check type: Restraint Seclusion[ Section 6. Definitions Race of resident is classified as W(White) B(Blacl<) H(Hispanic) 0(Other. including Native Amen. Asian) Restraint means a ?personal restraint" a ?mechanical restraint? or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include briefly holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident's body that he/she cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement: and (3) is not a standard treatment for the resident's medical or condition. Seduslon means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious [agar]; means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist, dentist, physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. of serious injuries include, but are not limited to: bums. lacerations requiring sutures. bone fracture. substantial hematomas, internal organ injuries. head injuries and sprains/suspected bone injury ierray is ordered. Suicide-Attempt is an acr that demonstrates some minimal non?zero intent to die as a result of the act.I This intent can be inferred if the not could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.1 The act under this definition includes implementing any steps to carry out a plan (it. putting a rope around one's neck).I A suicide attempt also includes attentionrseeking condUCt if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association of Suicidology; Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner. Brent. Lucas Gould. Stanley. Brown. Fisher. Zelazny. Burke. Oquendo. Mann. 1 Attempt De?nition Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development. inc. in collaboration with American Association of Suicidology: Revised October 2008. Page 3 of 4 000024 4/15/10 injury. Therefore. even if no physical Injury occurs during a suicide attempt. it should still be reported as a serious occurrence. per the federal reporting regulations. Page 4 of 4 000025 all15.$443314 88:53! HD 8953334649 P.E e. ea?l?l 'Il?l? I - F-r? 'lrf p'le - . tfucefoeeurreht?tteoei . Age: )8 ?2 3'14 Detonence location: it mediate noti?cation must be provided 14 hours after the occurrence or the ?rst work day ?oiiowing the occurrence whichever ii; men A representetive ?out Higdon Kill more verbally contact Rochelle Sharp. Higdon Hill Antietam Director or the covering House :ervisor IF the occurrence taken place on the weekend ALONG WITH. local admitting count)r DHR AND Gloria (De?ne) Holloway. Stale pertinent oft-lumen Resources. omen ot? Uceonurc 1-334?242-8177. In addition Wanda Jordan. Hill Crest Riel: Manager mutt be i?ed as the program must submit a report to State DHR. Of?ce ofLieeosure within 5 any: ofthe commence. by . I a tdott Hill Aset. Director noti?ed on (datcl'tirne) (ruff nan: chitin) no of noti?cation provided (circle applicable): Telephone occurrence notice use supmsei?edm notifiedon #57 (HS. name) (daler?timeJ (staff nameititi )e of noti?cation provided (circle voioemaii message, faxed occurrence notice County DER after hours noti?ed on $23 25'2?3 by (daytime) (staff natneittlle) attached phone list for admitting county alter-hours con tact umber} :e of noti?cation provided {circle applicabiwiephone voioemeil message. faxed occurrence notice 6- . . ne of After?home worker that responded .- -e occurrence 20 pence from worker covering the cell: i DHR, Gloria Holloway noti?ed on ill 71"! by 1: st: to (detcftimej of noti?cation provided (circle applicable): Telephone conversatio faxed occurrence notice roved family members noti?ed: Yes No Namefrelationship ofPerson noti?ed lied on by (dato?titne) 3 of noti?cation provided (circle applicable): Telephone conversation. telep 'lease list the County called and contact number called .- a to select the following: - . for any client at the facility or while participating in oft-site activities Oi Client Inlay-Ali injuries requiring medical treatment Seii?lnlury Accident Other facility activities which required professional 02 Client illness-any illness occurring at the litellity or while participating in off-site medical treatment. Yes No Dateofretum 03 Rome Please note i?'whelt clientretumedlo a rent Ifand received professional medical treannent) 04 Suicide! {client made an attempt to cause harm to se or durin offsite i'ecility activities 05 Death {Aux death occurringet the letting 3 steps must be completed ifallegatlons are made) 06 Suspected Abusemogioct (The following Verbal noti?cation to Hill Crest ltislr Me or one! oi??oelworlter. 2. CAN 07 Allegations of Sexual Funililrity (Sexual Familiarity includes but is no intercourse. or contact; and any form ofsexual contact) A. Employee to client B. *3 Olh?l': ?Fajita-15 ?Ahab-kitten WH-er ting Staff Sign more new Supervisor signatuteldau/ '1:an 0921-3 by) (locket 60 see mm oracle 1-334-353-2593 'on 1 . .(dttef?me) hone voicemail message, Faxed occurrence notice Child hot to ortlo DHR tsexual Client to client Wet-roe 8.96m repentance HILL .GRPUF: H0. 2658384649 .Toai?w?aeezeere 8-.1 lf? F?sll?igdou?HilIM Hourg'Occurrence'lthice . . 's?identName. Age: :urrence Time/Date: - Location: M/?mg, Nntil?lca Hon ncdiate noti?cation must be provided within 24 hours alter the occurrence or the ?rst work day following the occurrence. whichever is oer. A representative from Higdon Hill must verbally contact Rochelle Sharp, Higdon Hill Assistant Director or the covering House ervisor the occurrence talrce place on the weekend ALONG WITH, local admitting county DHR AND Gloria (Derico) Holloway. State orttnent of Human Resources, Of?ce of Licensure I-334-242-B 177. in addition. Wanda Jordan, Hill Crest Risk Manager must be tied as the program must submit a report to State [ill-[R1 Of?ce of Lleensure within 5 days of the occurrence. ion Hill Asst. Director noti?ed on :57 by lib/m MAWM i (deteitime) (sunna?mcrtirle) of noti?cation provided (circle applicable): Telephone conversation, telephone voicetnail mess faxed occurrence notice so Supervisor wad/'5? noti?ed on 1/2? - (HS. name) (datdtime) (staff nameltitle) of noti?cation provided (circle applicable-telephone voicemail message. faxed occurrence notice I34 Id vuln County DER after hours noti?ed on 2/25/(9? {5172? by mm ?Mia/I?m (care/time) 7 (staff attached phone list for admitting county cite of noti?cation provided (circle applicable): r- - - I uher ..- phone voiccmail message, faxed occurrence notice :oF A tier-l1 ours worker that respondcd?ra?tllt? occUn-er?e 1m aim datcr?tllpe 3/3? 3/5, ?9 ?7:19? arise Rom worker covering the call: Dita, Gloria Holloway noti?ed on 2/23/10! by ?ame: Minty/kn: ?7/77 (mommies) {dotcftime} I of noti?cation provided (circle applicable): Telephone conversation cphone voiccm all more faxed occurrence notice rved family members noti?ed: Yes a: No Namcr'rclationship ochrson noti?ed ed on by (date/time) (sta ff name/title) )f noti?cation provided (circle applicable): Telephone conversation. telephone voicemoil message, faxed occurrence notice also list the County celled and contact number called select the following: '1 Client Injury-All injuries requiring medical treatment for any client at the facility or while participating in off-site activities Self Injury Accident Other 2 Client illness-any illness occurring at the facility or while participating in offvsite facility activities which required professional medical treatment. Runaway Please note, it'l'when client rerurnedto progLam Yes No Date of return 4 Suicidal (client made an attempt to cause harm to self and received professional medical treatment) 5 Death (Any death occurring at the fa cilitv or during off site facility activities 6 Suspected AbusefNeglect (The following steps must be completed ifallcgationr are made) Verbal notification to Hill Crest Risk Manager local DHR of?cei?worlrer. 2. CLAN (Child Abuse 3: Neglect) report to DHR i' Allegations ofSexual Familiarity (Sexual Familiarity includes but is not limited to sexual intercourse with a client; deviant sexual intercourse. or contact; and any form of sexual contact) A. Employee to client B. Client to client 3 Other: [51..qu qunt-n?hw? r. WW {9??Eth?f? A i ng Staff Signature/dc 25 1' Supervisor signaturcfd? 38mm DHR Of?ce 1-334-353?2692; on 1.244% {33,51} . by Shun (dateltime) (Person i?nx?llg report) 0 0 1L, Derico, Gloria From: Jordan. Wanda Sent: Friday, February 28. 2014 4:24 PM To: psy21report?adap.ua.edu; Subject: 21 Serious Reports.14 Attachments: 21 Serious Reports.14, MCD.pdf Hi ti "Fag (555 i it hi3; 0* Hm PRI VILEGED AND CONFIDENTIAL PATIENT SAFETY WORK PRODUCT Wanda Jordan. R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham. Alabama 35212 305-838-4034 (phone) 205?838-4024 (fax) \x?aridn.inrtitln ?c?r?tlhsinexom Ul-lS of Delaware, Inc. Con?dentiality Notice: This e?mail message, including any attachments. is for the sole use oi?tho intended recipienl(s) and may contain con?dential and privileged information. Any unauthorized review. use. disclosure or distribution of this information is prohibited, and may be punishable by law. if this was sent to you in error. please notify the sender by reply e-mail and destroy all e0pies of the original message. 000028 L11 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21). as required in 42 C.F.R. 5 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama's Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DI-IR, the licensing agency; and the Legal Guardian of the resident. This. report must be submitted no later than the close of business the next business ?at! after a serious occurrence. Serious occurrences under the Act that must be reported include a resident's death (for any reason), serious injury (for any reason) to a resident as defined in 42 CPR 9483.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence. scan and email copies of this form to each of the three agencies identifiec_l_in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 4046627435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: February 26. 2014 25 Report of Serious Occurrence has been placed in resident record Februa_ry 28. 2014 i Alabama Departmental Alabama Disabilities Alabama Medicaid Agency Canterslor Medicare and Human Resources Advocacy Program Madman Services Regional Of?ce ADAP Executive Director Ms. Jan Sticka.. Program Ms. Susan Ward. Dir. Of?ce of Resource University of Alabama Manager Mental Health 3. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa. AL 35487- Montgomery, Alabama 36104 PO BOX 304000 0395 and fax l0 CMS Montgomery, AL 36130 334-353-4151 FAX 404-562-7435 334-353-2309 (fax) a 21m art sdlcaidmla a 334-242-1653 20 5-348-4928 0008195 4l15/10 Section 1. Facility Information: . 21 Facility Program name: Hill Crest Behavioral Health. Rise Unit . Street Addresstityi?ZIp 6369 5 Avenue South BimunghamJAlabama 35243 Telephone/Fax 2056384034 838-4024 fax Name/'1' itle of person completing report: Wanda lordan RN Director of Risk Management - Section 2. Resident information: Date of this report: February 28, 2014 Date/'1' ime of serious occurrence: February 26. 2014MB PM Resident full name- Resident date of birth: NamefAddresLPhe-ne of Guardian:? ment's Race: Gender: Female Dx: Bipolar Disorder Section 4. Report of a Suicide Attempt by a Resident Section 3. Report of a Serious Iniurv to a Resident: in the event of a suicide attempt that results in serious injury. complete BOTH Sections 3 and 4) -had been sitting in the dayroom listening to her IOP- Shuf?e, she laid her down and requested to go to the restroom. Upon leaving the restroom. -informed the nurse that she had cut the upper right area of right breast. -stated she had used a small piece of plastic that she had broken off her IPOD to cut herself. The nurse assessed the area and notified her physician and our CRNP. The CRNP noted a 1.6 inch laceration to her right breast. The laceration was repaired with 6 surures and a dressing was applied to the area. An antibiotic was prescribed to help We risk oi infection. She was instructed to keep the area dry. -tolerated the procedure well. stated she will be remove the sutures". For her safety, she was placed on one to one observation status. The morning of February the CRNP changed her dressing and noted there were no sign of infection or bleeding. A new dressing was applied. No further complication at this time. Date[ 1 ime of serious iniurg: 16, 2mg; [:25 PM Date/Time of the incident: Was resident in a restraint or seclusion at time of incident? 1 000030 4115110 Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation. MUST be reported to all agencies listed above. including MS Regional Office. Please submit Death Reporting Worksheet .. to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): - Dare/Time of death Was the resident in restraints or seclusion at time of death? Yes No Ii" yes.check type: Restraint[ Seclusion[ Section 6. Definitions gar-e of resident is classified as W(White) B(Black) i-l(i-lispanic) 0(Other. including Native Amen. Asian) Restraint means a "personal restraint" a ?mechanical restraint? or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricring the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident's body that hefshe cannot easily remove that restricts freedom of movement or normal access to ??lter body. Drug use as restraint means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement; and is not a standard treatment for the resident's medical or condition. Sec-fusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious Infuggmeans any signi?cant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor ?rst aid. Examples of serious iniarits include. but are no: limited to: barns. lacerations requiring sutures. bone fracture. substantial hemaromas. internal organ injuries. head injuries and sprains/suspected bone injury learay is ordered. Attempt is an act that demonstrates some minimal non?zero intent to die as a result of the act.I This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.2 The act under this definition includes implementing any steps to carry out a plan (ie. putting a rope around one's neck)." A suicide attempt also includes attention?seeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association of Suicidology: Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale developed by Posner. Ks Brent. 0.: Lucas 6.: Gould. M.: Stanley, 3.: Brown. Fisher. P4 Zelazny. Burke. Oquendo. Mann. I Attempt De?nition 1 Assessing and Managing Suicide Klein-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Doveiopmcat. inc. in collaboration with American Association of Suicidology; Revised October 2008. of 4 4/]5/10 injury. Therefore. even if no physical injury occurs during a suicide attempt, it should still be reported as a serious occurrence. per the federal reporting regulations. Page 4 of 4 000032 18:149 FROM2HIGDUN HILL GQDUP HU 2658384649 P.1 mm d- Sharp-Mammy. mm Director Higdon Hill Group ?miw To: Gloria Hallway, SDHR From: [\bk Fax: (334)353-2693 New 2 pm (334)242-8177 #912014 an ER wt? cc: Dugout For Mow Plum comm El Flt-n Ilaply Plou- Blank mm Page 1 000033 opp-seem 13:14:: WMIW HILL GREIJP Hi3 2053384349 P.E Hill Crertl?igdon Hill 24 Hour Occurrence Notice A- lleaideotlilme: Commence Tim (31:34: Occurrence Loeerinn: TM. turmediate noti?cation must he provided within 24 hours alter the occumnee or the ?rst work day following the occurrence. whichever is sooner. A representative from Higdon taunt verbally contact Rochelle Slurp, Higdon Hill Miriam Directorot' the covering House Supervisor the oectnrenoe tnitea phee on the neckend AMINO WITH. local Idrnilting county Oli'it AND Gloria (Dulce) Holloway, Slate Deparment of linear: Resources. Of?ce of Liceuswe 1434-2414177. in addition, Wanda Jordan. Hill Deal Riel: must be noti?ed as the prom must submit: minute Stone Of?ce ofLioensure within 5 days occturutce. Higdon Hill Asst. Directormti?edoo (vii-IA (3-11; pm? (datei'timo In?'mnto?itle) (a Type ofnoti?cttien provided (circle applicable): Telephone cmverna?on. tehphone voieemail message. faxed oocmce notice Win-k Home SupmimAi [Pr notified on by ate. name) (dole/time) {Moamu?ti?? Type ofnoti?earlcn provided (circle applicable): Telephone conversation, telephone volcemaii message, faxed oecmce notice Dim ammonia noti?ed on- gene 1.1L on (date/tine) {atefl'nam ?na- (See attached phone list for admitting enmity uteri-hours contact number) Type of noti?cation provided (circle applicable): Telephone convention- faxed acorn-rem enrich u- M. Name of Allah-hours waiter that responded to the commence A, detehime Response ll?orn worker covering the coil: State DER. Gloria Holloway noti?(Milne) Type of noti?cation provided (circle applicable): Telephone conversation, telephone voicanail message, Approved Emily when notified: Yen No Nomelrelatlonship of Person noti?ed Noti?ed on by (WW) (staff narneititle) Type of noti?cation provided (circle applicable): Telephone 00on telephone voieomeil manage. faxed occurrence notice Cpib?- Ce. ?bit?. Phone acieet the following: 0 Client injusyulii injurha requiring rioti'ui for any client at tho ?cllity or while article-tin: in off-tile eniviileo Homology Accident Other 02 Client illness n; at lacillty or iv to paling tn ofF-aite liciliiy netivitlet which required promotional trnalicll Went. 03 Ilse-tawny Pluto note, i?whcn client scanned to prom Yes No Dell: ofregnn__ Sujtg?gl (client made an in more harm toacii?lttd received profweionei medical cement) I35 Deeth [Anydeath occunirig?litc facilig or dining o?'slte facility nciivitiea . 06 Suspected Ahoacmweet ['i?he following steps must be completed ifaliegetions are made) I I. Vain] noti?cation in nan Cruel: Risk as local on: o?'leafvvoriter. 2. out 0'1 Allegations orSexual Familiarity [Satori Familiarity Includes but is not limited to anneal irneteourae with a client; deviant moral 'rntueoune, forrnofaeaoral contact) A. Employee to client 3. Client to client 03 Other: . i j? Miami-n? Reporting Staff swat: - Supervisor ?madden FuedtoSutte ouncem? Leas-353,259: by (Po-m Int report) Revised Sill 000034 BTMER HILL GROUP H0 26583842145 v.1 Hill Crest/Hi don Hill 24 Hoar Occurrence Notice gfagial? I f? Resident Name: Age: Occurrence ?l?ime/DatcOccurrence Location: Vernal Noti?cation inunediate noti?cation must be provided within 24 hours after the occurrence or the ?rst work day following the occurrence, whichever is sooner. A representative from Higdon Hill must verbally contact Rochelle Sharp, l-ligdon I-lill Assistant Director or the covering House Supervisor [Fibs occurrence takes place on the weekend ALONG WITH. local admitting county DER AND Gloria {Der-loo) Holloway. State Department of Human Resources, Of?ce of Licensurc 1-334-242-8177. In addition. Wanda Jordan, Hill Crest Risk Manager must be noti?ed as the program must submit a report to State DHR, Of?ce of Licensure within 5 days of the occurrence. Higdon Hill Asst. Director noti?ed on L3 [76? .2 f?n .u by 03!: MIA 733mb If}! i titanium) (staffnamoititlc) Type of noti?cation provided (circle applicable): Telephone conversation, telephone voicemai . faxed notice House Supervisor noti?ed out. 1:03; 21 ?2 5 by .1412ng I'd-22515 7993.1 (HS. name; (dot into) (staff namcitltle) Type of noti?cation provided [circle applicable): TWlephone voicemail message. faxed occurrence notice County DHR after hours noti?ed on by (datcftime) (staff name/title) (See attached phono list for admitting county a?crohours contact number) Type of noti?cation provided (circle applicable): Telephone conversation, tolcphono volccmail message, faxed occurrence notice Name ot'Aftcr-hours worker that responded to the occurrence dateltime Response from worker covering the call: State DHR, Gloria Holloway noti?ed on 3 ?74 by 5 26' M151: M195 ?r7 tu?'numea?litlo) . (datcltunc) a Type ofnoti?cation provided (circle applicable): Telephone conversation, telephone voiccnnail Inessagc. faxed occurrence notice Approved famii mom noti?ed: Yes or Narneirclationship of Fe on noti?ed . Eig 21dater'time} {staff nantcl'titlc) Type of noti?cation provided (circle applicable): Telephone conversation, telephone voiccmail message. faxed occurrence notice ??Pieeso list the County called (24kg! if! ,2 2:23 and contuctnumbcr called (225 221% (f it 92 Plcascselect the following: ill Client Injury-All injuries requiring medical moment for any client at the facility or while participating in off-site activities Accident Other 02 Client illness-any illness occurring at the facility or while participating in off-site facility activities which required professional medical treatment. 03 Runaway Please note. on client returned to program Yes No Date of return 04 Suicidal (client made an attempt to cause harm to self and received professional medical treatment) 05 Death (Any death occurring at the facility or during oft?sitc facility activities 06 Suspected [The following steps must be completed if allegations are made) I. Verbal noti?cation to Hill Crest Risk Manager dc local DHR officehvorker. 2. CAN (Child Abuse its Neglect) report to DHR m, 07 Allegations of Sexual Familiarity {Sexual Familiarity includes but is not limited to sexual intercourse with a client; deviant sexual intercourse, or contact; and any form of sexual contact) A. Employee to client B. Client to client 08 Oh: let A A Reporting StaffSignaturc/daic {dd deMj-f? '5 4A Supervisor signaturcldal . Faxed to State DHR Of?ce [434-353-2593 (in gill. dbl-9v by 5 . (datcltime) Person fart :1 report) .. Rev. 511 1 000035 HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-4034 FAX 205-838-4024 FACSIMILE TRANSMITTAL SHE ET T0: Mam Gloria De?dco Hollmvay wand- Jam-n mu. COMPANY: DATE: DHR State of Alabama 4-16-2014 m: NUMIIR: ram no. 0! man: emu: 334-353-2693 4 men: NUMBER: 334-242-8177 contained In thin hesim?c message is legally while? and con?dauli-l wimp-aw. which no intudnd only to: lb: mo of the indi?dmt or entity med Ihm. 1M: Irwin: of this u. not 111:. [nun-ltd ncipicm, you In hcuby noti?nl tint my an, ?nwminu?on. daauibll?ou a: ?product? of 6m meann- lt ltril?'lv ?Muted. ?Wu hiv- mnivcd munch: "ml. nod?' tho lander handing!? 6869 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 55212 000036 $522 44960196 Hill Crest Behavioral Health Services Mill 6869 5"1 Avenue South Birmingham, Alabama 35212 Date of Report: Agril 2014 Date/Time of Incidents: Agrii 11:;9 AM Group Home: Bessemer Group Home Report Received: Agrila, 201a nemma_ 0mm:? Name of Guardian: Race: ?lack Gender: Male Diagnosis: impulse gontrol Qisogdgr 9f lucidgm: -was horse playing around? In the classroom when he accidently hit his right thumb on a desk. The school staff assessed his injury and nail lied the group home staff. His right thumb was swollen, he was taken to a local emergency mom for avaiuatlon/treatment. An x-ray of his hand/thumb was negative for a fracture and dislocation. No treatment was necessary. He was returned back to the group home In stable condition-has not had any further complication from this incident. iWu leaf Director of Risk Management 000037 Ir 11?1- in @1in 32f; Hill Crest Behavioral Health Services 6869 5th Avenue South Birmingham, Alabama 35212 Date of Report: Agril lg. 3915 Date/Time of Incidents: and? ialzola? 1:50;: PM Group Home: Bessemer ?roug Home Report Received: ?grll 15, 2914 1.Resldent Name- Date of Birth:? Narne of Goa Race: Black Gender: Male Diagnosinm?mpi?r?gg 2. Resident Name:_ Date of Birth- Name oquardlan: Race: glac? Gender: Male Mood Qisorder Descrigtign of incident: - and -vere in the dayroom when they began to argue which lead to a physical altercation before staff could separate them. on assessment staff noted that - had a swollen left and was bitten on the right shoulder.? was taken to Growing-Up Pediatric for evaluation that afternoon. The physician noted there was no broken skin to his right shoulder and he had a contusion to the left we, no visual problems. No treatment was required and returned to the group home In stable candltion. He has not had any further complication from this incident. -did not receive any injuries from this incident. Mp growl Wanda orda Director of Risk Management 000038 Hill Crest Behavioral Health Services 6869 Avenue south Birmingham, Alabama 35212 Date of Report: Agrll 1.5I ?014 Date/Time of Incidents: Agril 7. 2914i 2:50 PM Group Home: Bessemer Group Home Report Received: amalgam? ResidentName- Date of Birth:? Name of Guardian: Racem Gender: Male Diagnosis: Anxiety Disorder ?esgriggign oi lggi?ent: .was arrested at school on April for having mariJuana In his possession. He was taken to detention at 2:50 PM by the local POlice. The police questioned him about the marijuana and he was released back to the group home later the some evening at 8:00PM-will be required to go to court at a future date for this incident. .informed staff he obtained the marijuana at school, than he stated he received it from a peer at the group home, but refused to give a name. staff see richer! the group home and the residents denied having any knowledge of marijuana at the group home. The searched did not produce anything evidence oi any illegal drugs. Di 000039 1 1 i 3:9 HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838~4034 FAX 205?838'4024 PACSIMILE TRANSMITTAL SHEET Ian-m TO: FROM: Glotia De??co Holloway Wanda Jordan Ml. COMPANY: Dug: DHR State of Alabama 4-25-14 MK NUMBER: TOTAL No. OF PAGES INCLUDING 334?353?2693 2 PHONE NUMBER: 334?242-8177 The informatiun contained in this facsimile message is :szy privileged and con?dential infumnion, which is intended Only for the use 0! the individual or entity named abovc. If the mad-2r of this message is not intended recipient, you are hereby noti?ed any use, dissemination. dism'bution or ?production ofthi: 1110?qu it atrictlv Drohihited. vauu hum: received this measure in :rmr. norlfv the sender immediately. 6869 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000040 1- .- Hill Crest Behavioral Health Services 5869 5"1 Avenue South Birmingham, Alabama 35212 Date of Report: Anrll g; 2914 Date/Time of incidents: i 13 - PM Group Home: Higgon Hill Group Home Report Received: Resident Name_ Date of Birth:? Name of Guardian:? Race: White Gender: Male Diagnosis: W: - reported he was taking a shower when he slipped and fell. Upon assessment, till nurse noted he had received a super?cial scratch to his right elbow with no broken skin. He denied having any pain or discomfort. A small hemotoml was noted to the top of his hood on tho right side, no bleeding or swelling. He also denied having any pain, headache, nausea, visual Issues or dizziness. -wos oriented times three and was lion. is physician was noti?ed who oral-mi that neurological checks as per our We! monitor rosidont closely. All of the neurological checks were within normal limits on had any other complications. Wanda lords RN Director 0f Management i 000041 Lil ?9?01qu iadirhta licensei L33 zine, nip} 45 Derico, Gloria Chiba) From: Jordan. Wanda Sent: Monday, April 28, 2014 3:40 PM To: psyereport@adap.ua.edu Subject: 21 Serious Reports.14. MCD.docx Attachments: 21 Serious Reports.14. MCDdocx Rise Unit incident AND CONFIDENTIAL PATIENT SAFETY WORK PRODUCT Wanda Jordan. R. N. Direclor of Risk Management 6869 Fifth Avenue South Bimiingham. Alabama 352 [2 205-838-4034 (phone) 205-838-4024 (fax UI of Delaware, Inc. Con?dentiality Notice: This e-mail message, including any attachments, is tor the sole use of the intended rceipient(s_) and may contain con?dential and privileged information. Any unauthorized review, use, disclosure or distribution 01? this information is prohibited, and may be punishable by law. Ii?lhis was sent to you in error. please notify the sender by reply e-mail and destroy all copies of the original message. 000042 4115/10 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21). as required in 42 CPR 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no la_ter than the close of business the next business dayr after a serious occurrence. Serious occurrences under the Act that must be reported include a resident's death (for any reason), serious injury (for any reason) to a resident as de?ned in 42 CPR M83352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of this form to each of the three agencies identified In the boxes below an_d enter one comr in the resident? record In addition, please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 40445625/435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: April 26, 2014 Report of Serious Occurrence has been placed in resident record April 28 2014 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Centers for Medicare and I Human Resources Advocacy Program Medicaid Services Regional Of?ce Ms. Susan Ward. Dir. Of?ce of ADAP Executive Director . Ms. Jan Sticker. Program Resource University of Alabama . Manager Mental Health 8 Gordon Persons Bullding Box 870395 501 Dexter Avenue 50 Ripley Street I Tuscaloosa, AL 35487? Montgomery. Alabama 36104 Efac?f?fm?ft" ?n P0 50" 304000 0395 and fax to CMS Montgomery, AL 36130 334-242-1653 205-348-4928 334-3534151 FAX mew-7435 334-353-2309 (fax) E3121renort?dhralabamaggv WW 95121rapgwmedinsidalgbamagov Section 1. Facility Information: 21 Facility/ Program name: Hill Crest Behavioral Health. Rise unit Street Address/City/Zip 6869 5th Avenue South Birmingham. Alabama 35212 Telephone/Fax 20548384034! 8384024 fax Name/Title of person completing report: Wanda Iordan RN Section 2. Resident Information: Date of this report April 28, 2014 Datefi'ime of serious occurrence: April 26. 2014! 7:15 PM i Resident full name- Resident date of birth: Name Address Phone of uardian: Resident's llace: ?1 Gender: Female Dx: Depression NOS Section 3. Report of a Serious Injury to a Resident: In the event of a suicide attempt that results in ous injury. complete BOTH Sections 3 and 4) ?requested to go to the bathroom. staff unlocked the bathroom door. out of the bathroom a few minutes later and showed staff she had cut her right forearm. stated she had used a small piece of glass she had found in the bathroom. The staff obtained the glass and placed it in the sharps box. Upon assessment. nurse noted -had a 2cm laceration to her right forearm. first aid was proved. When questioned about the incident. she stated, ?l'm tired being here". -Was sent for treatment to a local emergency room. She received 4 sutures 'ght forearm. She tolerated the procedure well and returned to our facility the same evening. as placed in scrubs. placed on 1:1 observation status for her safety. Staff will check the bathroom before she is alloWo enter and will closely monitor outside the dam-met with her therapist who believes that is harming herself to gain attention from her parents. ?are/Time of serious injury: April 26. 2014/ 17:15 PM Was the resident in restraints or seclusion at time of serious injurv? Yes fl No i if yes. check type: Restraint I Seclusion Section 4. Report of a Suicgle Attempt by a Resident Date/Time of the incident: Was resident in a restraint or seclusion at time of incident?I 000044 4l15/10 .- - - Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation. MUST be reported to all agencies listed above. including CMS Regional Of?ce. Please submit Death Reporting Worksheet to CMS in case of death) Description of the reported immediate cause of death and the events preceding death (attach additional documentation, including incident reports and medical reports): Date/Tune of death Was the resident in restraints or seclusion at time of death? Yes No If yes. check type: Restraint Seelusion Section 6. Definitions Race of resident is classified as WMhite) B(Black) H(i-iispanic) 0(Other. including Native Amen. Asian) Restraint means a ?personal restraint" a ?mechanical restraint" or "drug used as a restraint.? Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that he/she cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that (1) is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement: and (3) is not a standard treatment for the resident?s medical or condition. Seclusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious firm means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician?s assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial honatmnas. internal organ injuries. head injuries and sprains/suspected bone injury ifx?ray is ordered Enlarge ?rtemgris an act that demonstrates some minimal nonvzero intent to die as a result of the act.1 This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the siren rnstances of the incident. even if no harm actually resulted from the act:l The act under this definition includes implementing any steps to carry out a plan (it. putting a rope around one?s neck).I A suicide attempt also includes attentionvseeldng conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development. inc. in collaboration with American Association of Suicidology; Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posncr, Brent. Lucas Gould. Stanley. 3.: Brown. Fisher, Zeiamy. Burke. Oquendo. Mann. Attempt Definition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. Inc. in collaboration with American Association of Suicidology; Revised October 2008. 000 3&3 4 4/15/10 injury. Therefore, even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence. per the federal reporting regulations. 0003554 ?f4 1/12 I 3H5 mea 13 Jam ?73 Derico, Gloria From: Sent To: Subject: Attachments: Incident ?Rise Unit are?? 55 w; W) Jordan, Wanda Tuesday, April 29, 2014 4:51 PM psy21report@adap.ua.edu; DH 21 Serious RepOrts.14. MCDdocx 21 Serious Reports.14. MCD.docx PRIVILEGED AND CONFIDENTIAL Wanda Jordan, R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham, Alabama 35212 1205-8384034 (phone) 205-838-4024 (fax) not?ju UHS of Delaware, Inc. Con?dentiality Notice: This e?mail message. including any attachments, is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review, use, disclosure or distribution of this information is prohibited, and may be punishable bylaw. If this was sent to you in error, please notify the sender by reply c-mail and destroy all copies ot'the original message. 000047 4/15/10 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources DH R). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident's death (for any reason), serious injury (for any reason) to a resident as defined in 42 GER. 0483.352, or suicide attanpt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of thisjirm to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident's death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 4045627435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: April 28, 2014 5 Report of Serious Occurrence has been placed in resident record April 29 2014 Centers for Medicare and Medicaid Services Regional Of?ce Alabama Medicaid Agency Alabama Disabilities Advocacy Program Alabama Department of Human Resources Ms. Susan Ward. Dir. Of?ce of ADAP Executive Director Ms. Jan Slicka.. Program Resource University of Alabama Manager Mental Health 8. Gordon Parsons Building Box 870395 - 501 Dexter Avenue so Ripley Street Tuscaloosa. AL 35487- Montgomery, Alabama 36104 PO Box 304000 0395 and fax to CMS Montgomery. AL 36130 334-853-4151 FAX 404-562-7435 334.353.2309 (fax) gs?jragorl?madicaidmlabamagov 205-348-4928 arm?ream 334-242-1653 93121 ragcn?dhralgbamaggv ?4 4H5H0 Section 1. Facility information: 21 Facility/ Program name: Hill Crest Behavioral Health. Rise Uni; Street Address/City/Zip 6369 51th Avenue South Birmingham, Alabama. 35212 Telephone/Fax 2056334034! 83840244 fax Name/Title of person completing report: Wanda lordan RN . Director of Risk Management Section 2. Resident Information: Date of this report April 29, 2014 Date/Time of serious occurrence: April 23, 2014! 1:20 PM Resident full name_ Resident date of birth:- ameiAddress/ Phone of ardian: Resident's Race: Gender: Female Dx: Episodic Mood Disorder Section 3. Report of a Serious to a Resident: In the event of a suicide attempt that results in serious injury, complete BOTH Sections 3 and 4) Date/Time of serious injury: Was the resident in restraints or seclusion at time of serious injurycheck e: Restraint Seclusion - Section 4. Re ort of a Suicide Attemnt by a Resident - Happroached the nursing station crying. stated she could not do it anymore and ire needs to cave '5 place as soon as possible. Hi ?erapist attempted to process with her. stated she was depressed and was crying. goes to her room .close the door. Staff immediately opened the door and found she had placed a shirt around her neck. The shirt was taken from around her neck. no injuries were noted. no respiratory distress. All of personal belongs that she could use to .. harm herself were removed from her room and she was placed in paper scrubs for her safety. She was '5 also placed on suicide precautions. Datefi'irne of the incident: April 23. 2014 1:20 PM Was resident in a restraint or seclusion at time of incident? NO 000049 4/15/10 Section 5. Report of a Death of Resident (The death of a resident, regardless of circumstances or causation, MUST be reported to all agencies listed above, including CMS Regional Office. Please submit Death Reporting Worksheet . to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No if yes. check type: Restraint Seciusion Section 6. Definitions Race of resident is classi?ed as W(White) B(Blacl<) H(Hispanic) 0(Other. including Native Amen. Asian) Restraint means a ?personal restraint? a ?mechanical restraint" or ?drug used as a restraint." Personal restraint means the appliCation of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident's hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that he/she can not easily remove that restricts freedom of movement or normal access to his/her body. Drug use as resrraint means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident?s freedom of movement; and (3) is not a standard treatment for the resident's medical or condition. Seduslon means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious Inzury means any signi?cant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist, dentist, physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial hematomas. internal organ injuries. head injuries and sprains/suspected bone injury ifxaray is ordered Suicide Arremgris an act that demonstrates some minimal non?zero intent to die as a result of the act.l This intent can be inferred if the not could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.? The act under this definition includes implementing any steps to carry out a plan (Le. putting a rope around one?s neck).3 A suicide attempt also includes attention-seeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting ..- 1 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development, inc. in collaboration with American Association of Suicidology; Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale developed by Posner. Ks, Brent, Lucas Gould. Stanley. Brown, Fisher. Zelazny. Burke. As. Oquendo. Mann. 3 httpuiw l?CU-Posne r.ppt#936. I 2,Suicide Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development, inc. in collaboration with American Association of Suicidology; Revised October 2008. 000 dire 3 4/15/10 injury. Therefore. even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence. per the federal reporting regulations. Pa 4 0H 0000531 5 saw-20v} HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-8158410314 FAX 205-858-4024 FACSIMILE EA NSMITTAL SHEET TO: FROM: Gloria De?dco Hollawny Wanda Jordan RM. COMPANY: DATE: DHR Slate ofAlabama 5&14 FAX NUMBER: TOTAL NO. or ?1:133 INCLUDING comm 334-353-2693 2 mom: nuns?: 334-242-8177 The Momma-1 contained In thin facaimilc manage {9 leg-?y privilegtd and cm?dcntial iufms?m which II Only For the an: of the lndiw'dun! or entity named above. If reader grim! mung: not intendcd recipient, you arc na??cd that my me. diucminuu'on, dish-mutton or npmducmrl of mtumzc Ii alric?v nmhibiud. ?you have received this message in anal. ale?: nonifv the under 6869 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000052 Hill Crest Behavioral Health Services 6869 Avenue South Birmingham, Alabama 35212 Data of Report: Datefl'ime of incidents: Group Home: WW Report Received: Managua ResId-nmame- uncomm? Name of Guardian: Ream?bck Ganderz??il Diagnosis: Wm WM: -walked out of the group home the evening oi April 30?? when staff opened the door to allow a social worker for one of his peers intothe group home. Stuff encouraged -to return to the group homo, but hit refused and kept walking own the street. A police report was ?led with the Bessemer Police. His DHR worker was noti?ed of his eiopement. At this time his whereabouts are unknown. . Wanda .Iurda RN Director of Risk Management 000053 .I urn-.. . 55?.?ng Hi 5/2/5 gawk? r3; {Marry-M5. {2,4 (fr/Mt WY Derico. Gloria From: Jordan, Wanda Sent: Monday, April 28r 2014 3:57 PM To: p5y21report@adap.ua.edu; DH R_PSY21Report Subject: 21 Serious Reports.14. Attachments: 21 Serious Reports.l4. MCDdocx RTC Unit incident. PRIVILEGED AND CONFIDENTIAL Wanda Jordan, R. N. Director of Risk Management 6869 Fi?h Avenue South Birmingham, Alabama 35212 205-838-4034 (phone) 205-838-4024 (fax wands.iordanl?i?uhsinexo L11 UH of Delaware. lnc. Con?dentiality Notice: This c-mail message. including any attachments, is for the sole use ol? the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review. use. disclosure or distribution ofthis information is prohibited, and may be punishable by law. if this was sent to you in error, please notify the sender by reply e-mail and destroy all copies of the original message. 000054 4/l5/10 21 Serious Occurrence Reportingjorm This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21). as required in 42 C.F.R. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DI-IR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP). the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 CPR. s483352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition. please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the MS regional office may be submitted via fax at 4045624435. Document in the resident's record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: April 27, 2014 25 Report of Serious Occurrence has been placed in resident record A 11123 2014 '1 Centers for Medicare and Alabama Department of Alabama Disabilities Alabama Medicaid Agency Human Resources Advocacy Program Medicaid Services Regional Of?ce Ms. Susan Ward, Dir. Of?ce of ADAP Executive Director Ms. Jan Sticka,. Program Resource University of Alabama Manager Mental Health 8. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa. AL 35487- Montgomery, Alabama 36104 992%" PO BOX 304000 0395 Barr: and fax to ours Montgomery, AL 36130 334-242-1 653 205-348-4928 334-353-4151 334-353-2309 (fax) Egg reno?t?idhmlabamaoov 4/15/l0 . Section 1. Facility Information: 21 Facility/ Program name: Hill Crest Behavioral Health. RTC Unit Street Address/City/Zip 6869 51th Avenue South Birmingham. Alabama 35212 . Telephone/Fax 205?838?4034{ 8384024 fax Name/Title of person completing report: Wanda lordan RN Section 2. Resident Information: Date of this report April 28, 2014 Date/'1' ime of serious occurrence: April 2014f 9:30 AM Resident full name - Resident date of birth: - Residenthace: Gender: Male Dx: Depression NOS. Conduct Disorder Section 3. Report of a Serious Iniury to a Resident: In the event of a suicide attempt that results in serious injury. complete BOTH Sections 3 and 4) -became upset during CTM group, he started using profanity and stunned out of the group. While going to his room-punched a wall with his right hand. Once he became calm-informed staff his right hand was painful. He stated the pain was 6 on a pain scale of HO. Upon assessment the nurse noted his right hand and wrist was swollen, no broken skin. His physician ordered an xvray. The array results indicated a normal right wrist however his right 4?1? and 5 metacarpal was fractured. was sent to a local emergency room for treatment. His right hand was placed in a gutter splint an was instructed to followmp with an orthopedic. -tolerated the procedure and returned to our facility . the same evening.Just has an appointment with the Orthopedic on Tuesday April 29, 2014 at 2:30 PM. Datefl'ime of serious iniury: April 2014! 9:20 AM . Was the resident In restraints or seclusion at time of serious injury? Yes No 1 if yes. check type: Restraint Seclusion I Date/Time of the incident: Was resident in a restraint or seclusion at time of incident? 000056 Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation. MUST be reported to all agencies listed above. including CMS Regional Office. Please submit Death Reporting Worksheet to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation, including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No If yes. check type: Seclusion .. . . Section 6. Definitions Race of resident is classi?ed as W(White) B(Blacl() H(Hispanic) 0(0ther. including Native Amen. Asian) Restrafnrmeans a ?personal rest taint" a ?mechanical restraint" or ?drug Used as a restraint.? Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident's hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident's body that he/she cannot easily remove that restricts freedom of movement or normal access to hisfher body. Drug use as restraint means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident?s freedom of movement; and (3) is not a standard treatment for the resident's medical or condition. .S'mluslon means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. git-yous lawmcans any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received maybe provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial honatomas. internal organ injuries. head injuries and sprains/suspected bone injury levray is ordered. Suicide Atremgtis an act that demonstrates some minimal non-zero intent to die as a result of the act.1 This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.J The act under this definition includes implementing any steps to cany out a plan (Le. putting a rope around one's neck).I A suicide attempt also includes attention-seeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting 1 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. Inc. in collaboration with American Association of Suicidoiogy; Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner. Brent. Lucas Gould. Stanley. Brown. Fisher. Zelaany. Burke. Oquendo. Mann. 2 -0 2.5uicide Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association of Suicidoiogy; Revised October 2008. 000639? 3 injury. Therefore, even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence. per the federal reporting regulations. Pa 8 4 of4 ?nxi-g ?21m; it? law/@495 5 Maid-FiW?' Derico. Gloria From: Jordan, Wanda Sent: Thursday. May 22, 2014 5:38 PM To: psyerepon@adap.ua.edu; Subject: 21 Serious MCDdocx Attachments: 21 Serious Reports.14. MCD.doex CONFIDENTIAL PATIENT SAFETY WORK PRODUCT Wanda Jordan, R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham, Alabama 35212 205-838-4034 (phone) 205-838-4024 (fax .enm UHS of Delaware, Inc. Con?dentiality Notice: This e-maii message, including any attachments, is for the sole use oi? the intended reeipicnl(s) and may contain con?dential and privileged information. Any unauthorized review. use. disclosure or distribution this infomtation is prohibited. and may be punishable by low. li'this was sent to you in error, please notify the sender by reply email and destroy all copies oi'tlie original message. 000059 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient pwchiatric services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DI-IR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This repgrt must be submitted no later than the close of business the next business day after a ser?s occurrence. Serious occurrences under the Act that must be reported include a resident's death (for any reason), serious injury 0hr any reason) to a resident as defined in 42 C.F.R ?83.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence. scan and email copies of this form to each of the three agencies identifigcj?i the boxes below and enter one in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 404662'7435. Document in the resident's record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted Mag 19, 2014 Report of Serious Occurrence has been placed in resident record May 22 I 2014 . Alabama Department of i Alabama Disabilities Alabama Medicaid Agency Centers for Medicare and . Human Resources Advocacy Program Medicaid Services Regional Of?ce Ms. Susan Ward. Dir. Of?ce of ADAP Executive Director Ms. Jan Slicka,. Program Resource University of Alabama Manager Mental Health 8. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa, AL 35437. Montgomery, Alabama 36104 Efaags?iflm?f??i?t??I PO BOX 304000 0395 and fax to CMS Montgomery. AL 36130 334-353-4151 FAX 404-562-7435 334-353-2309 (fax) 205-348-4928 [:st1 334-242-1653 rm 4H5H0 Section 1. Facility Information: 21 Facility/ Program name: Hill Crest Behavioral Health. RTC Unit Street Address/City/Zip 6869 5'h Avenue South Birmimrham. Alabama 35212 Telephone/Fax305r833v4034f 8384024 [a_x Name/Title of person completing report: Wanda lordan RN Director of Risk Management Section 2. Resident Information: Date of this report Max 22, 2014 Date/Time of serious occurrence: Ma): 19, 2014! 7:00 PM Resident full name- Resident date of birth: - G?i?"i?im? Race: Gender: Male Dx: Anxiety Disorder Section 3. Report of a Serious lniurv to a Resident: In the event of a suicide attempt that results in serious injury. complete BOTH Sections 3 and 4) -was in the playing basketball with his peers when he was accidently elbowed in the right eye. Staff returned him to the unit to be assessed by the nurse. The unit nurse assessed him and noted a small inch cut above his right eyelid with minimal bleeding. The nurse applied pressure and applied an ice pack to his right to stop the bleeding. His physician was notified and referred him to a local emergency room for treatment. The emergency physician cleaned the area and closed the laceration which was 0.5cin with wound adhesivefinderm. He tolerated the procedure well and returned to the Facility the same evening. -denied having any vision problems. DatefTirne of serious injury: May 19. 2014! 7:00 PM Was the resident in restraints or secl_u_s?ion at time of serious inju rv? Yes No i i If yes, check tv?pe: Restraint Seclusion I I l+ 1 Section 4. Report of a Suicide Attempt by a Resident Date/Time of the incident: I Was resident in a restraint or seclusion at time of incident? 000061 - - Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation, MUST be reported to all agencies listed above. including CMS Regional Office. Please submit Death Reporting-EWorksheet to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No if yes. check type: Restraint[ Seclusion[ Section 6. Definitions Race of resident is classified as W(White) B(Biack) l-l(l-iispanic) 0(Other. including Native Amen. Asian) Resrraint means a ?personal restraint" a ?mechanical restraint? or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that he/she cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement: and (3) is not a standard treatment for the resident?s medical or condition. Series-ion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious Injury means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: bums. lacerations requiring sutures. bone fracture. substantial hematomas. internal organ injuries. head injuries and sprains/suspected bone injury ifxlray is ordered. Suicide Acre-mgr is an act that demonstrates some minimal intent to die as a result of the act.1 This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.? The act under this definition includes implementing any steps to carry our :1 plan (Le. putting a rope around one?s neck).1 A suicide attempt also includes attentionrseelting conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. Inc. in collaboration with American Association of Suicidology; Revised October 2008. citing "Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner, Brent, D.: Lucas C.: Gould. Ms. Stanley. 3.: Brown. Fisher, Zelazny, Burke. Oqucndo. Mann. 1 Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals: Suicide Prevention Resource Center. Education Development, Inc. in collaboration with American Association of Suicidology: Revised October 2008. 3 ?f4 4H5H0 injury. Therefore, even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence, per the federal reporting regulations. Page 4 0? 000063 Hill Crest Behavioral Health Services 6859 Avenue South Birmingham, Alabama 35212 Date of Report: May; zeta Date/Time of incidents: Mg! Lg?l? 7:30 am Group Heme: Bessemer Boys Group Home Report Received: Mag 23 2014 Resident Name- Date of Birth- Name of Guardia Race: Black Gender: Male Diagnosis: Digorggr The fence behind the group was damage during the storm on Apr-5123, 2014. All residents were Informed not to enter the area until further notice. On Thursday May 01, 2014,- went into the area and stepped on a hall with his right foot. Staff assessed his foot and noti?ed our CRN P- Carrie Sanders who assessed his right foot. Ms. Sanders cleaned the area on his right foot and gave- a tetanus injection for prophylactic measures. No further treatment was required. At the time of this report no further issues have been voiced b- The group home staff noti?ed his DHR worker the day of the incident. Director of Risk Management 000064 6H ?94; HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-833-4034 FAX 205~838-4024 5/ 7490/?de 5% M44 5? 972/" 5?75 FACSIMILE TRANSMITTAL SHEET 10' FROM: Glon'a De?rico Holloway Wanda Jordan RM. DATE: DHR State ofAanama 5-22-14 MK TOTAL Mucus 334?353-2693 3 Fla?0N1; NUMBER: 334442-3177 Note: Attached report for_ is a correction ofhis date ofbitth. Please disregaxd the previous report- Th: Information canuintd in thi: facsimile mung: in legally p??icgod Ind m?dmdu which ?5 intendzd only ?x the use ol?iha individual or entity numed abort. .ll'lhr. madcr of this manage in no: {hr intended recipiaut, you are bushy nu??cd that my "It. dlm'ihution or 1:9dean 0! this message in snicdv mhibitcd. If van have mceivcd this manage in plum unti?r Eu- mlder 6369 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000065 Hill Crest Behavioral Health Servlces 6869 Avenue South Birmingham, Alabama 35212 Date of Report: Date/Time WM Group Home: Report Received: M43921 Raf-8:91:93 Gender: Male Wm= .Naihed out oftho group home the evening of April 30?? when staff opened the door to allow a social worker for one of his peers into the group home. Staff encouraged to return to the group homo, but he refused and kept walking down the street. A police roport was filed with the Bessemer Police. His worker was noti?ed of his elopemont. At this time his whereabouts are unknown. Wanda lorda RN Director of Risk Monanmont 000066 . - "Fr? - pj512913f 11115 inulttj 1:5 Gianni? '5 $51313;in Derico, Gloria From: Jordan, Wanda b/?i i270 Sent: Thursday. May 29, 2014 7:36 PM To: psyereport?adap.ua.edu; Subject: 21 Serious Reports. 14. Attachments: 21 Serious Reports.14. MCDdocx PRIVILEGEI) AND CONFIDENTIAL PATIENT SAFETY WORK PRODUCT Wanda Jordan. R. N. Director ol'Risk Management 6869 1'7 ilih Avenue South Birmingham, Alabama 35212 205?838-4034 (phone) 205-838-4024 (fax 1.1 :111tl;1.jortli1n "Et' ol Delaware lne.Cont?1dentialit3 Notice: lhis e- -111uil message including any attachments is for the sole use of the intended recipient(s) and may contain con?dential and privileged intormation. Any unauthorized review use. disclosure or distribution ol this information Is prohibited and 111.33 be punishable b3 law. It this was sent to you in error please notil:r the sender by repl3 e- -n1t1il and destr03 all copies ol the original message. 000067 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 C.F.R. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama's Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP). the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident's death (for any reason), serious injury (for any reason) to a resident as de?ned in 42 CFR 3483.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious Occurrence, scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (C MS) regional of?ce before close of business the next business day after the resident's death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 404-562-7435. Document in the resident's record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent andfor legal guardian has been contacted: May 28I 2014 3 Report of Serious Occurrence has been placed in resident record May 29 2014 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Centers for Medicare and Human Resources Advocacy Program - Medicaid Services Regional Of?ce Ms. Susan Ward. Dir. Of?ce of ADAP Executive Director Ms. Jan Sticka,, Program Resource University of Alabama Manager Mental Health 3. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa. AL 35487- Montgomery. Alabama 36104 P0 50" 304000 PRTF: and lax to CMS Montgomery, AL 36130 334-353-4151 FAX 404-562-7435 334-353-2309 (fax) 205-343-4928 334-242-1653 95121 regg?thmiabamagg 1 of4 4H5H0 l?ection 1. Facility information: i 2] Facility! Program name: Hill Crest Behavioral Health. RTC Unit Street Address/Citnyip 6869 5th Avenue South Birmingham, Alabama 35;; Telephone/Fax 205?333?4034.? 338?4024 fax Name/Title of person completing report: Wancgjordan RN Director of Risk Management i Section 2. Resident Information: Date of this report: May 29 2014 Date/Time of serious occurrence: May 27. 2014! 10:00 PM Resident full name;- Resident date of birth: - Name/rinddress!r Phone of Guar Race: Gender: Male Dx: Oppositional Defiant Disorder in serious injury. complete BOTH Sections 3 and 4] returned from a TLOA with father the evening of May 27'? at approx. 7:30 PM. He interacted with his peers. After hygiene time-alleged he fell while taking a shower. however he did not report it until a few hours later when the nurse was replacing his Dynasplint on his left arm. he asked her ?does it look funny?. noted no swelling or bruising. skin intact, he denied having pain. His roommate stated-Wold him he had fallen at home, riding his 4rwheeler. Morning of May 23*, his left arm was reassessed swelling was noted, he . denied pain. only discomfort when he attempted to bend his left arm. -was sent to a local ER [or evaluation! treatment. The array revealed a fracture near the base of the rod in his left arm. A long arm cast was applied to his left arm and he was referred to an orthopedic surgeon for follow-up due to the rod in his left arm. He returned to the facility the same evening. At this time it is unsure if his left arm will require sorgery or any further treatment. Orthopedic follow-vup is scheduled forjune 3, 20M. His DHR worker and father were notified of the accident. His father voiced he re of any falls or injuries while he was at home with him. Prior to his admission to Hill Crest as in an auto accident which resulted to him havin an ortho edit: rod in his left er arm. Datefl?ime of serious iniurv: Mar 2014/ 10:00 PM Was the resident in restraints or seclusion at time of serious iniu DatefTime of the incident: Was resident in a restraint or seclr?ion at time of incident? 000069 4ll?ll0 . a resident, regardless of circumstances or causation, MUST be reported to all agencies lisred above. including CMS Regional Office. Please submit Death Reporting Worksheet .. to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional docu mentation. including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No If yes, check type: Restraint Seclusion Section 6. De?nitions Raceof resident is classified as W(White) B(Blacl<) H(Hispanic) 0(0ther. including Native Amen. Asian) Restralnrmeans a ?personal restraint? a ?mechanical restraint? or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident's body that hefshe cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that (1) is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident?s freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. genomic}: means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious Indra means any significant impairment of the physiCal condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial hnnatornas. internal organ injuries. head injuries and sprain sfsuspectrd bone injury ifX-ray is ordered. Suicide?gremgris an act that demonstrates some minimal non-zero intent to die as a result of the act.I This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the ac t.1 The act under this definition includes implementing any steps to carry out a plan (it. putting a rope around one?s neck).1 A suicide attempt also includes attentionvseeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting 1 Assessing and Managing Suicide RisloCore competencies for University and College Mental Health Professionals: Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association of Suicidology; Revised October 2&03. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner. Brent. Lucas Gould, Stanley. Brown. Fisher. Zelazny. Burke. Oquendo. Mann. 1 ?.l2.Suicide Anempl De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals: Suicide Prevention Resource Center. Education Develop ment, Inc. in collaboration with American Association of Suicidolom October 2008. Page 3 of 4 4II5HU injury. Therefore. even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence. per the federal reporting regulations. Page 4 0? 000071 ?In ?Wile (tilt - 1015631 57?" barbed. li?e?w (gt/?SH Derico, Gloria From: Jordan, Wanda Sent: Thursday. June 12, 2014 7:25 PM To: psy21report?adap.ua.edu Subject: 21 Serious Reports.14. MCD.docx Attachments: 21 Serious MCD.docx Incident Wanda Jordan, R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham, Alabama 35212 205-838-4034 (phone) 2058384024 (fax wandeiordani?juhsinecnm UHS of Delaware, Inc. Con?dentiality Notice: This email message, including any attachments, is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review, use, disclosure or distribution of this information is prohibited, and may be punishable by law. 11" this was sent to you in error, please notify the sender by reply e?mail and destroy all copies of the original message. 000072 4/I5l10 21 Serious Occurrence ReportingForm This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21). as required in 42 C.F.R. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report most be submitted no later than the close of business the next business dav after a serious occurrence. Serious occurrences under the Act that must be reported include a resident's death 0m" any reason), serious injury (for any reason) to a resident as defined in 42 C. FR. 5483.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence. scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. in addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 40415624435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: lune 9, 2014 5 Report of Serious Occurrence has been placed in resident record une l2 2014 . Centers for Medicare and Medicaid Services Regional Of?ce Alabama Disabilities Alabama Medicaid Agency Advocacy Program Alabama Department of Human Resources Ms. Susan Ward, Dir. Of?ce of ADAP Executive Director Ms. Jan Sticka,, Program Resource University of Alabama Manager Mental Health S. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa. AL 35487- Montgomery. Alabama 36104 PO BOX 304000 and fax to cus Montgomery. AL 36130 334-353-4151 FAX 404-562-7435 334-353-2309 (fax) 334-2424 653 Page I of 4 4H5H0 Section 1. Facility Information: 21 Facility Program name: Hill Crest Behavioral Health. Rise Unit Street Addressz?Ciwaip 6869 5th Avenue South Birmingham, Alabama 35212 Telephone/Fax 205v838~4034i 83840231 fax Name/Title of person completing report: Wanda lordan RN Director of Risk Management Section 2. Resident Information: Date of this report: lune 12, 2014 Date/Time of serious occurrence: lune 9.3914/ 7:30 PM Resident full name_ Resident date of birth:? Namei'Addressf Phone [1qu Race: Gender: Female Dx: Conduct Disorder . Section 3. Report ofa Serious injury to a Residen serious injury. complete BOTH Sections 3 and 4] - was in the dayroom when she thought she heard some of her peers laughing at her. She walked over. . picked up a chair and threw it across the room. She Started threatening to assault her peers. Staff instructed her to go to her room. When-got in her room. she began punching a wall several times . before stall" could intervene. Upon assessment. her right hand was red. swollen and bruised. First aid was provided. The physician on-call ordered an x?ray. The array results indicated a fracture in midvshaft of the fifth metacarpal. She was sent to a local emergency room for treatment. Her right hand/arm was placed in an ulnar-?gutter splint and was referred to an orthopedic for followaup. She returned to the facility the same evening. On june 12m,-was evaluated and treated by an orthopedic. Her right . hand/arm wa ed in a short arm cast. She tolerated the procedure well and returned to the facility the same day. has a follow?up appointment with the orthopedic in three weeks. Date/Time of serious iniurv: lune9, 2014! ?:30 PM Was the resident in restraints or seclusion at time of serious iniurv? Yes No If ves. check type: Restraint Seclusion [j I i. _u Date?'ime of the incident: Was resident in a restraint or seclusion at time of incident? 000074 4115/10 causation, MUST be reported to all agencies listed above, including CMS Regional Office. Please submit Death Reporting Worksheet .. to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation, including incident reports and medical reports): . Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No If yes. check type: Restraint Seclusion Section 6. Definitions Race- of resident is classified as W(White) B(Black) H(Hispanic) 0(0ther. including Native Amen, Asian) Restraint means a ?personal restraint? a ?mechanical restraint? or ?drug used as a restraint.? Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident's hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident's body that hefshe cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that (1) is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident?s freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. Sedusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious Jargon-means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath, podiatrist, dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include, but are not limited to: bums. lacerations requiring sutures. bone fracture. substantial hematomas. internal organ injuries. head injuries and sprains/suspected bone injury ifx'ray is ordered. Suicide Arcana: is an act that demonstrates some minimal nonvzero intent to die as a result of the act.? This intent can be inferred if the ac: could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.2 The act under this definition includes implementing any steps to carry out a plan (Le. putting a rope around one?s neck).3 A suicide attempt also includes attention-seeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development, inc. in collaboration with American Association of Suicidology; Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner, K.: Brent. Lucas Gould. M.: Stanley, Brown, Fisher, Zelazny, Burke, Oquendo. Mann. 1 Attempt De?nition 1 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals: Suicide Prevention Resource Center, Education Development, inc. in collaboration with American Association of Suicidology: Revised October 2008. 000075 Page 3 of 4 4115/?) injury. Therefore. even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence. per the reporting regulations. 4 of 4 r? ?2m Slawbti?ht?gaj rim/Hm IIFLW LI Derico, Gloria From: Jordan, Wanda Sent: Tuesday, June 17, 2014 6:13 PM To: psy21rep0n@adap.ua.edu; Subject: 21 Serious Reports,14, MCD.docx Attachments: 21 Serious Reports.l4. MCDdocx AN CONFIDENTIAL PATIENT SAFETY WORK PRODUCT Wanda Jordan, R. N, Director of Risk Management 6869 Fifth Avenue South Birmingham Alabama 35212 205-838-4034 (phone) 205-838-4024 (fax wanton. UHS of Delaware, Inc. Con iidcntieiity Notice: This email message, including any attachments, is for the sole use of the intended rccipienl(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution of this information is prohibited, and may be punishable by law. il?this was sent to you in error, please notii'y the sender by reply e-niaii and destroy all copies of the original message. 000077 4/15/10 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama's Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This re ort must be submitted no later than the close of business the nexr business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident's death (for any reason), serious injury (for any reason) to a resident (is de?ned in 42 CPR. 5483.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of _tl;i_s form to each of the three a encies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the MS regional office may be submitted via fax at 4045624435. Document in the resident?s record that a death was also reported to the MS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: [une16, 2014 5 Report of Serious Occurrence has been placed in resident record lune 17 2014 - Alabama Disabilities Alabama Medicaid Agency Advocacy Program Alabama Department of Human Resources Medicaid Services Regional Of?ce Ms. Susan Ward. Dir. Of?ce of I ADAP Executive Director Ms. Jan Silcka., Program Resource Mgmi University of Alabama Manager Mental Health 8. Gordon Parsons Building Box 870395 501 Dexter Avenue so Ripley Street Tuscaloosa. AL 35437- Montgomery. Alabama 36104 Eff: PO BOX 304000 0395 Parr; and fax to cars Montgomery, AL 36130 334-353-4151 334-353-2309 (fax) - 334-242-1853 205-348-4926 4/15/10 Section 1. Facility information: 21 Facility/ Program name: Hill Crest Behavioral Health. Rise Unit Street Address/City/Zip 6869 5? Avenue South Birmingham. Alabama 35212 Telephone/Fax 205638-4034} 8384024 fax Name/Title of person completing report: Wanda lordan RN Director of Risk Management Section 2. Resident Information: 1 Date of this report: lune 1 Z, 2014 Date/Time of serious occurrence: lune 16, 2014! 5:20 PM Resident full name_ Resident date of birth: NamefAddressf Phone of Guardian: grace: 'i Gender: Female Dx: Bipolar Disorder Datefl'ime of serious injure: Was the resident in restraints or seclusion at. time of serious injuryyesl check wpe: Restraint seclusion i Section 4. Re on: of a Suicide Attempt by a Resident -was in the bathroom ap roxirnately 5?7 minutes, sta?? knocked on the door. Stat?l? did not receive an answer so he opened ?It door-p-W?s lying on the ?oor, face down 1with a white T-shirt tied around her neck. Staff immediately removed the T-cbirt, and called for help. Her oxygen level was 99% on room air, was not in any distress and was able to speak without dif?culty. She was uncooperative, yelling at staff that she wants to die and not to touch her?. The nurse noted she had used a zip tie to rub several abrasions to th [cit side of her neck and above her left breast. She was given a PRN medication to help calm her down. irefused to let the nurse to provide first aid but ?nally agreed to have the areas cleaned and ointment applied. No further treatment was necessary. She was placed on a one to one observation status. placed in paper scrubs and all items that she could use to harm herself were removed from her room. At this time,-is still on a one to one observation status. She is participating with her peers In on unit activities. 000079 Date/Time of the incident: june 16 2014/ 7:20 PM Was tangent in a restraint or seclusion at time of incident? Mn 4/15/10 - Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation. MUST be reported to all agencies listed above. including CMS Regional Of?ce. Please submit Death Reporting Worksheet .. to CMS in case of death) Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No if yes.check type: Restraint[ Seclusion[ Section 6. Definitions Race of resident is classi?ed as was/hue) B(Black) H(Hispanic) 0(Other. including Native Amen. Asian) Restraintmeans a ?personal restraint" a ?mechanical restraint" or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident's body that hefshe cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that (1) is administered to manage a resident?s behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident?s freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. Seclusfon means the involuntary con?nement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious qu'uggmeans any signi?cant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include, but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial hematomas. internal organ injuries. head injuries and sprains/suspected bone injury is ordered Suicide Attempt is an act that demonstrates some minimal non'zero intent to die as a result of the act.I This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.?I The act under this de?nition includes implementing any steps to carry out a plan (Le. putting a rope around one?s neck).1 A suicide attempt also includes attention-seeking conduct if the conduct can be viewed as porentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development, Inc. in collaboration with American Association of Suicidology; Revised October 2003. citing ?Columbia Suicide-Severity Rating Scale developed by Posner. Brent. Lucas Gould. Stanley. 13.; Brown. Fisher. Zelazny. J..- Burke. Oquendo. Mann. 2 Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development. Inc. in collaboration with American Association of Suicidology; Revised October 2008. 3 of4 4/151?) injury. Therefore. if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence, per the federal reporting regulations. 000081 Page 4 of 4 25W 26 HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838r4034 FAX 205~838~4024 FACSIMILE TRANSMITTAL SHEET To: FROM: (310x253 De?rico Holloway Wanda Jordan R.H. CD3IPANY: DATE: DHR State ofAszamz 6-23?14 mx NUMEER: TOTAL NO. or mans mcwoms covam 334-353-2693 2 PHONE NUMBBR: 354442317? The information committed in thin facsimile mung: is privileged and inmmudun. which is intended nnly for the van: a! the individual or antin- named above. If the under 01' thin mung: is not (11: rucipicm, you In noti?ed um my an, diaacwinuion, diqiribub'un u! tepmducdon hf this laminate is uricdv Prohibited. If van have this manage in error. plane nudfv the 31min Immedinlelv. 6869 FIFTH AVENUE SOUTH BIRMINGHAM. JALABAMA 35212 000082 Hill Crest Behavioral Health Services 5869 5mAvonue South Birmingham, Alabama 35212 Date of Report: June 23. 2014 Date/Time of Incidents: June 29.20143 4:01} PM Group Hum?fif-Bl?ssemww Report Received: June 23, 2014 a Resident Name_ Date of Birth:? Name of Guardian: . Race: Black Gender: Male Diagnosis: Conduct Disorder Deserlntign of incident: The resident walked out the front door of the you home. Staff encouraged him to return to the group home but he kept walking. A report was filed with the Bessemer police. He did not return so he was discharged from the group home on June 20, 2014 at 11:59 PM as per our policy. The morning of June 21, 2014 the resident's mother wanted to leave -t the group home. The staff informed her that the resident had been discharged and she would need to call his DHR worker. The Director of the group home was informed that -was allowed to stay with his mother. Mair Wanda Jor RN Director of Risk Management 000083 9% Wig; Derico, Gloria From: Jordan, Wanda Sent: Friday, June 20. 2014 2:21 PM To: psyereport?adap.ua.edu; Subject: 21 Serious Reports.14. MCD.docx Attachments: 21 Serious Reports.l4. MCDdocx Wanda Jordan, R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham, Alabama 35212 205-838-4034 (phone) 205-838-4024 (fax wands.iordatriiaultsi necnm {a UHS of Delaware, Inc. Con?dentiality Notice: This e-mail message, including any attachments. is tor the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review. use, disclosure or distribution of this information is prohibited, and may be punishable by law. if this was sent to you in error. please notify the sender by reply e-mail and destroy all cepies of the original message. 000084 4/15/10 11 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DI-IR). Each 21 facility is required to report any and all serious occurrences to: Alabama's Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no_13ter than the close of business the next business day _a_fter a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 C.F.R. 6483.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of this form to each of the three _ag_encies identified in the boxes below and enter one copy in the resident?s record. in addition. please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional of?ce may be submitted via fax at 404562 -?435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: une 13, 2014 Report of Serious Occurrence has been placed in resident record une 20 2014 Alabama Alabama Medicaid Agency Advocacy Program Alabama Department of Human Resources Medicaid Services Regional Office Ms. Susan Ward, Dir. Of?ce of ADAP Executive Director Ms. Jan Sticka,, Program Resource Mgmi University of Alabama Manager Mental Health 8. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street - Tuscaloosa. AL 35487- Montgomery, Alabama 36104 genagszifgm?r?s?g P0 30* 304000 Parr: and fax to one Montgomery. AL 36130 334?353-4151 FAX 404-562-7435 334-353-2309 (fax) 25121rgpo??medicaldniabammg? 205-348-4928 334-242-1653 of 4 4/]5/l0 FSection 1. Facility Information: 21 Facility! Program name: Hill Crest Behavioral Health. Hi don Hill Grou Home Street Addresstity/Zip 6869 5' Avenue South Birmingham. Alabama 35212 Telephone/Fax 205838?4034! 838-4024 fax Name/Title of person completing report: Wanda Iordan RN Director of Risk Management I - Section 2. Resident Information: Date of this report [one 20, 2014 Date/1? ime of serious occurrenceiunc 18, 2014! 3:55 PM Resident full name;? Resident date of birth: Race: W) Gender: Female Dx: Episodic Mood Disorder . Section 3. Report of a Serious lniury to a Resident: serious injury, complete BOTH Sections 3 and 4] Date/Time of serious injury: Was the resident in restraints or seclusion at time of serious in'u Yes No if yes, check tyne: Restraint Seclusion[ 1 Section 4. Report of a Suicide Attem Resident While making rounds, staff found ?in the bathroo to to both wrists. Staff immediately notified the nurse. Upon assessment, the nurse noted thawed superficial cuts to her wrists and bilateral lower arms which had been bleeding, but ha clotted off. Her physician was notified of the injury. No sutures were necess uts were cleaned, triple antibiotic ointment applied and covered with nonstick bandages. mdmitted using her razor to cut herself. She stated she could not promise not to harm herself LE she was left alone. Her physician placed her on one to one observation while awake for her safety. - 000086 Date/Time of the incident: lune 18. 2014/ 3:55 PM Was resident in a restraint m- swine? -. is- - - - The death of a resident. regardless of circumstances or causation. reported to all agencies listed above, including CMS Regional Office. Please submit Death Repottlnir Worksheet - to CMS in case of death) Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No if yes. check type: Restraint Seclusion Section 6. De?nitions Race of resident is classified as W(White) B(Black) H(Hispanic) 0(Other. including Native Amen. Asian) Restraint means a ?personal restraint" a ?mechanical restraint" or "drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include briefly holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident's body that he/she cannot easily remove that restricrs freedom of movement or normal access to hisfh er body. Drug use as restraint means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. Sedusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Sedans from means any signi?cant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician?s assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care heapital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: burns, lacerations requiring sutures. bone fracture. substantial hematomas. internal organ injuries. head injuries and sprains/suspected bone injury [varay is ordered. Suicide Arte-mgr is an act that demonstrates some minimal non-zero intent to die as a result of the act.l This intent can be inferred if the act could be viewed as porentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.2 The act under this definition includes implementing any steps to carry out a plan (Le. putting a rope around one?s neck).3 A suicide attempt also includes attentionvseeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting 1 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education DechOpmenl, Inc. in collaboration with American Association of Soicidoiogy; Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Pusner. Brent, 0.: Lucas Gould. M.: Stanley. Brown. 6.: Fisher, chamy, Burke. An: Oquendo. Mann, Attempt De?nition Assessing and Managing Suicide Risk~Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development, inc. in collaboration with American Association of Suicldolp?h?g?ped October 2008. Page 3 of 4 4/15f10 injury. Therefore. even if no physical injury occurs during a suicide attempt, it should still be reported as a serious occurrence, per the federal reporting regulations. 000088 Page 4 of 4 . Derico, Gloria From: Jordan, Wanda Sent: Friday, June 20, 2014 2:21 PM To: psyerepon@adap.ua.edu Subject: 21 Serious Reports.14. MCD.clocx Attachments: 21 Serious Reports.14. MCDdocx Wanda Jordan, R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham. Alabama 35212 205-338-4034 (phone) 205-838-4024 (fax wantiu. of Delaware. Inc. Con?dentiality Notice: This e?mail message, including any attaclunents. is for the sole use of the intended recipieni(s_) and may contain con?dential and privileged information. Any unauthorized review. use, disclosure or distribution of this information is prohibited. and may be punishable bylaw. lfthis was sent to you in error. please notify the sender by reply e-mail and destroy all copies of the original message. 000089 4115110 21 Serious Occurrence REFORM Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama's Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP). the state designated Protection and Advocacy system; DHR. the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 CPR. $483,352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence scan and email copies of this form to each of the three agencies identi?ed in the boxes below and enter one copy in the resident?s record. In addition. please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at: 4046624435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: une 18, 2014 Report of Serious Occurrence has been placed in resident record lune 20 2014 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Centers for Medicare and Human Resources Advocacy Program Services Regional Office Ms. Susan Ward. Dir. Of?ce of ADAP Executive Director Ms. Jan Sticka., Program Resource University of Alabama Manager Mental Health 8. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa, AL 35487- Montgomery, Alabama 36104 PO BOX 304000 and fax to cars . Montgomery. AL 36130 334-353-4151 334-353-2309 (fax) - 205-348-4928 gsyzirgpg??adagmaedu 334-242-1653 minimums 4/I5/l0 Section 1. Facility Information: 2] Facility/ Program name: Hill Crest Behavioral Health. Rise Unit Street Addresstityi'Zip 6869 ?lth?Avenue South Birmingham, Alabama 35212 TelephonefFax 205638?4034! 8384024 fax Name/Title of person completing report: Wanda Iordan RN Director of Risk Manaeemenr a. Section 2. Resident Information: Date of this report 1 lune 20, 2014 Date/Time of serious occurrence: lune 18; 20?] 4:45 PM Resident full name_ Resident date of birth:? Gender: Female Dx: Conduct Disorder - vv?r~ Section 3. Report of a Serious Iniury to a Resident: . serious injury, complete BOTH Sections 3 and 4] In the event of a suicide attempt that results in -becarne upset because she could not go on an outing with her peers due to her behavior. She went into her room a few minutes later and reopened a previous scar on her right forearm. Upon assessment, the nurse notified -physician who ordered a medical consult with our CRNP. The CRNP assessed her right forearm and closed the wound with one ?pu uture? and placed a dressing over the site to help prevent the resident from picking at the suture. ?tolerated the procedure well. The suture is scheduled to be removed on june 26, 2014. DatefTime of serious iniurv: Lune 18. 2014! 4:45 PM Was the resident in rem-ems or seclusion at time of serious iniury? Yes No If yes. check woe: Restraint Seclusion Section 4. Report of a Suicide Attempt by a Resident DatefTime of the incident: Was resident in a. restraint or seclusion at time of incident? 000091 4/15/10 Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation. MUST be reported to all agencies listed above. including CMS Regional Office. Please submit Death - to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documents tion, including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No if yes. check type: Restraint Seclusion a Section 6. De?nitions Race of resident is classi?ed as W(White) B(Black) H(Hispanic) 0(Other, including Native Amen. Asian) Restraint means a ?personal restraint? a ?mechanical restraint" or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that he/she cannor easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary elfect of restricting the resident?s freedom of movement; and (3) is not a standard treatment for the resident's medical or condition. Scciusfon means the involuntary confinement of a. resident alone in a room or an area from which the resident is physically prevented from leaving. Serious InMymeans any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical dottor, osteopath. podiatrist. dentist. physician?s assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture, substantial hematomas. internal organ injuries, head injuries and sprains/suspected bone injury ifX-ray is ordered. Suicide Attempt is an act that demonstrates some minimal non-zero intent to die as a result of the act.? This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident, even if no harm actually resulted from the act.2 The act under this definition includes implementing any steps to carry out a plan putting a nope around one's neck).J A suicide attempt also includes attention?seeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development inc. in collaboration with American Association of Suicidoiogy; Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) deve10ped by Posner, K4 Brent, Lucas Gould. Stanley. Brown, Fisher, Zeiazny, Burke, Oquendo. Mann, 2 [2.3uieide Attempt De?nition 3 Assessing and Managing Suicide Risk?Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development. inc. In collaboration with American Association of Suicidology; Revised October 2008. 000092 Page 3 of 4 4/15/10 injury. Therefore. even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence. per the federal reporting regulations. 000093 Page 4 of4 65'? (9 ?Oil/0 HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-338-4034 FAX 205-838-4024 FACSIMILE TRANSMITTAL SHEET TO: now Gloria Dc?ztco Holloway Wand: Jordan ILN. commw: mm: UHR State of?l?bama 7-8-14 mac NUMBER: -. TOTAL. NO. or: mans INCLUDING covaa: 334?353-2693 2 PHONE NUMBER: 334442-8177 'I'hc inl'urm-tion contained in this facsimii-z Inn-usage in Legally privileged and can?dmtial Information, which it: intended only for Ike us: of the individual ur rarity named above. If the rude: oi 111i! manage in notth1_ intended recipient, you are hernby nmilicd that any usg, or reproduction of tin! menu: it micdv prohibited. 11'qu luv: much-w this manner in "car. plane norifv the under immudialelv. . 1 ALABAMA 35212 6869 AVENUE SOUTH BIRMINGHAM 000094 Hill Crest Behavioral Health Services 6869 Avenue South Birmingham, Alabama 35212 Date of Report: g, go 15 Date/Time of Incidents: Group Home: Report Received: mm Resident Name- Date of Birth: Race: mg Gender: we Diagnosis: mm Minimum: -wes In front of the group home and stopped on a brick which caused a superficially cut her heel. Upon assessment, the nurse noted a small cut, the size of a dim- to her left heel. There were no bloodlng, no swelling, no drainage hmever the area was pink. The area was cleaned with soap and water a triple antibiotic ointment and a hand aid was applied enled ahv pain or discomfort. tolerated the procedure well. Her physician and her DHR worker were notified of the incident. At this time, no further complication or complath have been reported. WW rm Wanda Jorda RN Director of llioir Management 000095 156,11?, 19W) HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-4034 FAX 205-838~4024 FACSIMILE TRANSMITTAL SHEET TO: FROM: Gloda De'tico Holloway Wanda Jordan RN. EBEJPANY: one: DHR State ofAlabama 7-14-14 mu: NUMBER: TOTAL NO. or use: INCLUDING comm 334-353-2693 ?3 PHONE. NUMBER: 334?242-3177 The information contained in thi: facsimile men-gt la privileged and con?duuliil informn?un, wl?ch i! inlandcd only fur 1h: use uf the individull or ?unity shave. Nth: tunic: of this many: in no: inumd-cd tecipicnt, you In: heat-15* noti?ed that my uut. ditscminatlon. ?scribution nr unproducdofl of message in wicdv prohibited. If mu ham: receive-.11! thin mean: in error. plea" nuuif'v the lc?drr 6869 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000096 Hill Crest Behavioral Health Servicns 6869 Avenue South Birmingham, Alabama 35212 Date of Report: 19]! 2914 Date/Time of Incidents: WM Group HOME: Wm Report Received: mm Resident Name- Date of Birth: - Name of Guardian: Race: Gender: Male DiagnosiS: -was playing basketball with H: pears and staff was In attends non-ran for the ball and mldontly fall Into a wlndow oftho group home. Staff immodiately ran to his assistance and noted his right hand was bleeding and 911 was called. Tho paramedics evaluated his Injury of super?cial cuts/scratches to three of his fingers on his right hand. The area was cleaned and a dressing was applied to his right hand, no furthor treatment was requlrad.-toleratad the procedural will. At this time, no further complication or have been reported. W, Wanda lord: RN Dlroctor of Risk Management 000097 39> 449W HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT FAX 205-838-4024 PHONE 205-838-4034 FACSIMILE SHEET TO.- FROM: Gloria De?rico Holloway Wanda Jordan ILN. gummy: uns- DHR State ofAlabanm 7-17-44 13} NUMBER: mm. NO. onus as mcnunma coma: 3314-3534693 2 mow; wusam 334-242-8177 6569 FIFTH AVENUE SOUTH Th: Mamas-tier: contained in [hit facsimile: message: is legally privileged and cun?dcn?at informatian, which. is intended nnly fur the use of the ludjx-iduul or entity named above. If 01? ?nder of this manage nut Intended Incipient, ynu an: hmby noti?ed Ihal any we, disncminution, diatributinn a: rmwducuun of muslin: is itricth nrth'biled. If have waived this meant: in error. ulna." no??r the under BIRMINGHAM. ALABAMA 35212 um 000098 Hill Crest Behavioral Health Services 6859 Avenue South Birmingham. Alabama 35212 Date of Report: July 12. 2014 Date/Time of Incldents: WW Group Home: mm Report Received: July 15, 3014 Resident Name- Date of Birth:? Race: 31951:. Gender: ml: Diagnosis: ti lei n: -walked away from the group home on Tuesday. Staff stated he did not dismay any behaviors that would Indicate an atonement. Staff was unable to apprehend him. An elopement report was ?led with the local pollen. His DHR worker was notified of his elopoment by the group home director. At this ti me, the resident's whereabouts are unknown. Wanda Jordan RN Director of Risk Management 000099 1?sz HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-4034 FAX 205?838-4024 FACSIMILE TRANSMITTAL SHEET TO: FROM: Gloria De'ricn Holloway Wanda Jordan MI. DATE: DHR State of Alabama 7-30-14 FAX NUMBER: TOTAL NO. OF PAGES INCLUDING COVER: 334-353-2693 PHONE NUMBER: 33%242-8177 The informadnn cunnincd in this fuc?imilc mess-g: in legally and wn?dcnliai infurmudon. which Is intended only for the use or the individual 0: ?11!in named above. If the reader of thin is not the. recipienl. you in: herch nodfied that any use, diucmimu?on, distribution or reproduction of?ng messian- iu stric?v If wu haw. received this message in error. alum: notifv the sender immedjuttlv. lw' 6869 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000100 Hill Crest Behavioral Health Services 6859 5'h Avenue South Birmingham, Alabama 35212 Date of Report: MM Date/Time of Incidents: MW Group Home: Wm Report Received: any 1215 Resident Name- Date of Birth: mum Gender: Male W: -was playing basketball with his peers and mined his right ankle. Upon assessment the nurse noted the ankle had slight swelling however the resident was ambulatlr? without my dif?culty and his salt was steady. He was instructed to keep his ankle elevated and minimize his walking until further evaluation. His physician was notified and an way was ordered to rule Out a possible fracture. had an arr-ray on Monday July 28?? which was nee-?ve for a fracture/dislocation. however the x-roy results was not received until today. At this time, -has not voiced any further issue with his right ankle and no further treatinent has been required, WM 7% Wanda Jordan RN Director of Management 000101 939 V64 Sent: Thursday, August 14, 2014 6:30 PM To: psyereport?adap.ua.edu; Subject: 21 Serious Reports.14. MCD.docx Attachments: 21 Serious Reports,14. MCD.docx Incident. Wanda Jordan? R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham, Alabama 35212 205-838-4034 (phone) 205-838-4024 (fax wande. iordnn?j?uhsineeom UHS oi' Delaware. Inc. Con?dentiality Notice: This e-muil message, including any attachments, is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review, use, disclosure or distribution efthis information is prohibited, and may be punishable by law. ?this was sent to you in error, please notify the sender by reply email and destroy all copies of the original message. 000102 4/]5/l0 4: 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21). as required in 42 CPR 483.374 and which have a provider agreement with Alabama Department of Human Resources (DI-IR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency: Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. Ibis report must be submitted no later than the close of business the next business clayr a_fter a serious occurrence. Serious occurrences under the Act that mu at be reported include a resident's death (for any reason), serious injury (for any reason) to a resident as defined in 42 CPR. $483,352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence. sean and email: copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident's death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 404-562-7435. Document in the resident?s record that a death was also reported to the MS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted August 10, 2014 3 Report of Serious Occurrence has been placed in resident record August 2014 Alabama Disabilities Alabama Medicaid Agency Centers for Medicare and Alabama Department of Human Resources Advocacy Program I: Medicaid 33mm - Regional Office Ms. Susan Ward, Dir. Of?ce of ADAP Execub?ve Director Ms. Jan Sticka,. Program univeariiya?ilrii'sbm S. Gordon Persons ur 50 Ripley Street 9 Tuscaloosa. AL 35487- Montgomery, Alabama 36104 Efgagssl?oung?a?g . PO BOX 304000 - El?fg and fax to one Montgomery. AL 36130 334-242-1653 334-353-4151 334-353-2309 {flit} osv21 mciab. 4/l5/10 Section 1. Facility Information: 21 Facility I Program name: Hill Crest Behavioral Health. RTC Unit Street Addressfi?Jity/Zip 6869 Avenue South Birmingham. Alabama 35212 Telephone/Fax 2056384034! 83840244 fax Name/Title of person completing report: Wandajordan Director of Risk Management Section 2. Resident information: Date of this report August 13, 2014 Date/Time of serious occurrence: August 2014! 6:30 PM Resident full name? Resident date of birth: NamefAddre Race: (W Gender: Male Dx: Post Traumatic Stress Disorder Section 3. Report of a Serious?iurv to a Resident: In the event of a suicide attempt that results in serious injury, complete BOTH Sections 3 and 4} was in the dayroom with his peers and staff, he got up started walking toward the hall when he passed out and fell to the ?oor. Per staff he loss conscious for less than two minutes. Staff nurse immediately assessed him vital signs were within normal range, breathing unlabored. He was able to speak without dif?culty. He was alert and oriented He had a small laceration to his chin, minimal bleeding. When asked 1what had happens res nded I don' His physician sent him to Children?s Hospital Emergency Department for treatment? received three sutures to his chin, an uncomplicated fractured tooth and a concussion. tolerated the procedure well and returned to the facility the same evening. He has a follow-up appointment with Children?s Neuro Clinic in two or as a dental appointment with UAB School of Dentistry on August 14, 2014. At this time, has not voiced any further complaints. Datef?l'ime of serious injury: August 10. 2014,4530 PM Was the resident in restraints or seclusion at time of serious iniur? Yes No 1' X) if ves,check type: Restraint Seclusionl Datefl' i me of the incident: Was resident in a restraint or seclusion at time of incident? 0001 04 4/15/10 or causation. MUST be reported to all agencies listed above. including MS Regional Office. Please submit Death Reporting Worksheet to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/Tune of death Was the resident in restraints or seclusion at time of death? Yes No If yes, check type: Restraint[ Seclusion[ . - Section 6. Definitions Race of resident is classi?ed as W(White) B(Black) H(Hispanic) 0(Other. including Native Amen. Asian) Restraint means a ?personal restraint" a ?mechanical restraint? or "drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident's hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that he/she cannot easily remove that restricts freedom of movement or normal access to hislher body. Drug use as restraint means any drug that (1) is adndnistered to manage a resident?s behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. Sedusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious Inter}; means any signi?cant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include, but are not limited to: burns. lacerations requiring sutures. bone fracture, substantial hematomas. internal organ injuries. head injuries and sprains/suspected bone injury ifX?ray is ordered Suicide Arte-mgr is an act that demonstrates some minimal non?zeto intent to die as a result of the act.1 This intent can be inferred if the ac: could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.? The act under this definition includes implementing any steps to carry out a plan (ie. putting a rope around one?s neck).? A suicide attempt also includes attentionrseeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide- Prevenlion Resource Center, Education Development, Inc. in collaboration with American Association of Suicidology; Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner, Brent, Lucas Gould, Stanley. 3.: Brown. Fisher. Zelamy, Burke. Ac; Oquendo. Mann. 2 Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals: Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association of SuicidologY: Revised October 2008. 000105 Page 3 of 4 4/15/[0 injury. Therefore, even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence, per the federal reporting regulations. 000109333 4 0H HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205~838~4034 FAX 205-838?4024 FACSIMILE TRANSMITTAL SHEET 'ro: Pkou: Glo?a Dc?rico Holloway Wanda Jordan R.N. COMPANY: ppm: DHR State of Alabama 9-9-10 FAX TOTAL NO. OF PAGES INCLUDING COVER.- 334-353-2693 2 wow: NUMBER: 33+242~3177 The information contained in Ihta Izmir-til: mung: is legally privileged and mn?den?d which inwndad only for the use of the individual or named above. ?the made: of dais mung: net Um. tech-lint. rm: are huchy nou??ud {hat In}- Usc, dinicminmion. diurn'budon reproducdn-n of shalt manna is au-iutlv ntohibilcd. If you turn remind tin?: mcuaage In error. ulna: no?fv under unmtmuelv. -.- m-u-v 6369 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000107 Hill Crest Behavioral Health Services 6859 Avenue South Birmingham, Alabama 35212 Date of Report: WM Datemma of incidents: Enigmgor 1. 191418;? EM Grow Home: Report Received: W5 ResidentN-me_ Darwinian:- ?mumm? Race: Gender: M111: Diagm5 515?u?ii?LQIm rl tl l' cl -walkod away tram the group home last Thursday evening. For his poem-pushed an a door and ran away. Staff was unable to locate him. A police roport was completed with the Bessemer police-case number 0904140151. His Drill worker was Ilsa noti?ed of his oiopement. Staff stated -did not display any behaviors of sloping prior to the incident. Tuesday September Ms. Rocha": Sharp-Marbury, Group Home Director was noti?ed that had been located at home in the Bessemer area. DHR worker stated he would be picked up today. No known injury or criminal activity occurred during his elopement. The plan Dlilt has at this time is that Jeremiah will be readmitted to Iammer Group Home or at ngdon Hill Group Home. 47%.er Wanda Jordan RN Director of Risk ManagerrIent 0001 08 -1.. . a a?d U'-t Deri?n, Gloria From: Jordan, Wanda Sent: Tuesday, September 23, 2014 5:51 PM To: Subject: 21 Serious Reports.l4. MCD.docx Attachments: 21 Serious Reportsl4. MCD.docx Incident on September 22. 2014 Wanda Jordan, R. N. Director of Risk Management 6869 Fifth Avenue South Birmingham. Alabama 35212 205-838-4034 (phone) 205-838-4024 (fax) wands.iordm?uhsineeom UHS of Delaware, Inc. Con?dentiality Notice: This e-mail message. including any attachments. is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review. use. disclosure or distribution of this information is prohibited, and may be punishable by law. If this was sent to you in error. please notify the sender by reply e-mail and destroy all copies of the original message. 000109 4/l5/10 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occgnence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 C. ER. 5483.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence scan and email copies of this form to each of the three identified in the boxes and enter one conv in the resident 3 record In addition please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 4045627435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: September 22 2014 Report of Serious Occurrence has been placed' in resident record September 23, 2014 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Centers for Medicare and Human Resources Advocacy Program Medicaid Services Regional Of?ce Ms. Susan Ward. Dir. Of?ce of I ADAP Executive Director Ms. Jan Sticka., Program Resource University of Alabama Manager Mental Health 3. Gordon Persons Building Box 870395 501 Dexter Avenue I 50 Ripley Street Tuscaloosa, AL 35487- Montgomery. Alabama 36104 . gram?? . PO BOX 304000 0395 and fax to CMS Montgomery. AL 36130 334-353-4151 FAX 404-562-7435 334-353-2309 (fax5348-4928 psygiragort?adag. ua. edu 334-242-1653 93121rugo?dhralahamagov 0001 ?Page I OH 4H5H0 Section 1. Facility Information: 21 Facility /Program name: Hill Crest Behavioral Health. CrTearn Unit Street Address/City/Zip 6869 5 Avenue South Birmingham, Alabama 35212 TelephonelFax 2056384034! 8384024 fax Namef'l'itle of person completing report: Wandajordan RN Director of Risk Management Section 2. Resident Information: Date of this report: September 23, 2014 Date/Time of serious occurrence: Sentll. 201?? 3:00 PM Resident full name_ Resident date of birth: We! Phone oquardian: Gender: Female Dx: Depressive Disorder serious injury, complete BOTH Sections 3 and 4] became upset and cut her right forearm while she was in the bathroom. The unit nurse assessed the resident and noted two lacerations to her right forearm. The area was cleaned and her physician was noti?ed who referred her to our CRNP for treatment. Our CRNP closed the lacerations with auto res, i'our sutures to each laceration. tolerated the procedure well. Staff questioned why she had cut herself, she would a say. When asked what she had used she stated she had used a lancer a peer had given her. was placed in scrubs, her room was searched and all items that she could use to harm herself were removed from her room. The peer that had given her the lancet was also placed in scrubs and her room was searched for contraband, nothing was found. and the peer were placed on safety precautions. Date/Time of serious iniurv: Sept. 22. g014/ 3:00 PM Was the resident in restraints or seclusion at time of serious iniuggcheck 1: e: Restraint Seclusion Date?'ime of the incident: Was resident in a restraint or seclusion at time of incident? 000111 4/l5/l0 Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation. MUST be reported to all agencies Listed above. including CMS Regional Office. Please submit Death Reporting Worksheet - to CMS in case of death Description of the reported immediate cause of death and the even ts preceding death (attach additional documentation, including incident reports and medical reports): Date/Time of death Was the residentin restraints or seclusion at time of death? Yes No if yes. check type: Restraint Seclusion Section 6. Definitions Race of resident is classified as W(White) B(Blacl<) H(Hispanic) 0(Other. including Native Amen. Asian) Restraint means a ?personal restraint" a ?mechanical restraint? or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident's hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident's body that hefshe cannot easily remove that restricts freedom of movement or normal access to hislher body. Drug use as restraint means any drug that is administered to manage a resident?s behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident?s freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious any signi?cant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assisrant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial hematamas. internal organ injuries. head injuries and sprains/suspected bone injury ifx'ray is ordered. Sul?de A tremgt is an act that demonstrates some minimal nonazero intent to die as a result of the acr.I This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.? The act under this definition includes implementing any steps to carry out a plan (it. putting a rope around one's neck).? A suicide attempt also includes attentionrseelting conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education DechOpment. Inc. in collaboration with American Association of Suicidology: Revised October 2003. citing ?Columbia Suicide-Severity Rating Scale developed by Posner. Brent. Lucas Gould. Stanley. Brown. Fisher. Zelazny. Burke, Oquendo. Mann. 2 Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association of Suicidoloy; Revised October 2008. 0001 1 2 Page 3 of 4 4/15110 injury. Therefore, even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence, per the federal reporting regulations. 0001 1I?tge 4 0H Derico. Gloria From: Sent: To: Cc: Subject: Attachments: Wanda Jordan RN Director of Risk Management in {1 MM Jordan, Wanda Tuesday, October 07, 2014 9:21 AM psy21report@adap.ua.edu 21 Serious Reports.14. MCD 21 Serious Reports.l4t MCD.docx Hill Crest Behavioral Health Services 6869 Fifth Avenue South Binningham, Alabama 352 [2 Of?ce 205-338-4034 Fax 205-838-4024 UHS Inc. Con?dentiality Notice: This e-mail messa use of the intended recipient(?s) and may contain con?dential review. use, disclosure or distribution of was sent to you in error. please notify the sender by reply email and destroy this is prohibited. and may be punishable all c0pies of the original message? 1 000114 ge, including any attachments, lb tor the sole and privileged information. Any unauthorized by law. tt?this i . 4-?15-?10 21 Serious Occurrence Reporting Form i . ibis reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 4.2: C.F.R. ii 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrence?i to: Alabama's Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR1 the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must he reported include a resident?s death (for any reason). serious injury (forany reason) to a resident as defined in 42 C. ER. 6483.352, orsuitide attempt by it resident. See Section 6 for definitions. I Please print or type the requested information below. For each serious occurrence, scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 40415627435. Document in the resident?s record that a death was also reported to the CMS Regional OffiCeg' i Please check the following when completed and include date: Parent andfor legal guardian has been contacted October 4, 2014, 2014 Report of Serious Occurrence has been placed in resident record October 6. 2014 1 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Centers for Medicare and Human Resources Advocacy Program Medicaid Senses Regional Office Ms. Susan Ward, Dir. Office of ADAP Executive Director Ms. Jan Siicka,, Program i Resource Mgmi University of Alabama Manager Mental Health 1' S. Gordon Persons Building Box 870395 501 DexterAvenue -. 50 Ripley Street Tuscaloosa. AL 35487- Montgomery. Alabama 36104 PO 50* 304000 0395 and fax is ours Montgomery, AL 36130 i 334-242-1653 205-348-4928 334-353-4151 FAX 40456217435 334-353-2309 (fax) 5 mthrenon?iadaDMH-Edu ,1 00?11 ?age I oi'4 i 41510 Section 1. Facility Information: 2 l?acility Program name' l'lill Crest Behavioral Health. RTC Unit 686.9 5'h Avenue South Birmingham,Alahama 35212 'i?elephone?liix 8384024 fax Namci'l?itle ofperson completing reportzj-Vanda ordan RN Director of Risk Management I Section 2. Resident Information: Date of this report: October 6: 20H Date-?lime olserious occurrence: Octo_her 41 2014l?9150 PM Resident full name;- Resident date oi hitthi Race: Gender: Female Dx: Post Traumatic Stress Disorder Section 3. Report of a Serious iniurv to a Resident: In the event of a suicide attempt that results in serious injury. complete BOTH Sections Band 4} ofserious injury: the resident in restraints or seclusion at time of serious in'mtv? Yes lLNo X) if yes; cheek type: Restraint] I Seclusionl Section 4? Report of a Suicide Attempt by a Resident -rcported to staff that she had used a plastic soa container to make superficial scratches on her left arm. The superficial Scratch was from her left elbow to her left wrist. first aid w- ?tied. no i visihle bleeding and er treatment was necessary. The unit nurse questioned why she had harmed herself. stated she was hearing voices that she was worthless and it was her fault that her sister was heat to death. She also stated she had blacked out while she. had se 11th her-sell i ier physician was notified who placed i'laylee on suicide precautions, placed her in paper scrubs and one to one observation while awake for her safety. All items that she could use to harm herself were removed from her room. . . . 000116 Datei'l?ime ol the Incident October 4,3014 at 9:30 PM: \N'as resident in a restraint or seclusion at time of incident? 4/15/10 l?ection 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causatlon. MUST be reported to all agencies listed above. including CMS Regional Of?ce. Please submit Death Reporting Worksheet to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No if yes. check type: Restraint Seclusion Section 6. Definitions Race of resident is classified as W(White) B(Black) H(Hispanic) 0(Other. including Native Amen. Asian) Restraint means a ?personal restraint? a ?mechanical restraint" or ?drug used as a restraint.? Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident?s body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that hefshe cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement; and (3) is not a standard treatment for the resident's medical or condition. Seclcsion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious {cry :3 means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial hemaromas. internal organ injuries. head injuries and sprains/suspected bone injury ivaray is ordered. Suicide Attemptis an act that demonstrates some minimal nonrzero intent to die as a result of the acr.l This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.?I The act under this definition includes implementing any steps to carry out a plan (to. putting a rope around one?s neck).3 A suicide attempt also includes attention-seeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development, Inc. in collaboration with American Association of Suicidology: Revised October 2003. citing "Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner. Brent. 0.: Lucas Gould. Ms. Stanley. Brown. Fisher. Zciaany. Burke. Ar. Oquendo. Mann. 2 Attempt Definition Assessing and Managing Suicide RiSlErCOrc competencies for University and College Mental Health Professionals: Suicide Prevention Resource Center. Education Developman inc. in collaboration with American Association of Suicidolcgy; Revised October 2008. 0001 17 Page 3 of4 4/15/10 injury. Therefore, cven if no physical injury occurs during a suicide attempt. it should still be reported as a minus occurrence, per the federal reporting regulations. a 0001 1 8m 4 0" I [2/59, [lug/f6? )25' gerico, Gloria From: Jordan, Wanda Sent: Tuesday, November 04, 2014 5:46 PM To: psy21rep0n@adap.ua.edu; Subject: 21 Serious Reports.14. MCD Attachments: 21 Serious Reports.14. MCD.docx Wanda Jordan RN Director of Risk Management Hill Crest Behavioral Health Services 6869 Fifth Avenue South Birmingham, Alabama 35212 Of?ce 205-838-4034 Fax 205-838-4024 UHS of Delaware, Inc. Con?dentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review. use. disclosure or distribution of this information is prohibited, and may be punishable by law. If this was sent to you in error, please notify the sender by reply e-mail and destroy all copies of the original message. 0001 1 9 4/15/10 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama's Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident?s death (for any reason), serious injury (for any reason) to a resident as defined in 42 CFR 5483.352. or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence. scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 404662-7435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: November 3, 2014 5 Report of Serious Occurrence has been placed in resident record November 43014 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Human Resources Advocacy Program Medicaid Services Regional Office Ms. Susan Ward. Dir. Of?ce of ADAP Executive Director Ms. Jan Sticka.. Program Resource Mg'mt University of Alabama Manager Mental Health . S. Gordon Persons Building Box 670395 501 Dexter Avenue 50 Rlpley Street Tuscaloosa, AL 35487- Montgomery, Alabama 36104 PO BOX 304000 mg; nd fax to one Montgomery, AL 36130 334-353-4151 FAX 4M562-7435 334-353-2309 (fax) a . abama. cv 334-242-1653 1 0H 4/15/10 Section 1. Facility information: 2! Fae?ity/ Program name: Hill Crest Behavioral Health. RISE Unit Street Address/City/Zip 6369 S'F'Avenue South Birmingham. Alabama 35212 Telephone/Fax 7105-8384034! 838-4024 fax Name/Title of person completing report: Wanda lordan RN Director of Risk Managgnent Section 2. Resident Information: Date of this report: November 4. 2014 Date/Time of serious occurrence: November 3, 2014! 10:25 AM Resident full name- Resident date of birth:- Name Address! Phon dian: Race: W) Gender: Female Dx: Depressive Disorder Section 3. Re on of a Serious 1n to a Resident: While walking down the stairs to the school tripped over her foot and fell down four-live steps. The staff immediately ran found or lying on her hack on the ?oor. The nurse assessed her and noted the following: was alert and responsive, was able to answer questions. no broken skin, bleeding or swelling. She never loss consciences. She complained with neck and arm pain. Upon the paramedics? arrival, was able to respond to their questions. She placed her on a back board as a precaution. No en or was required. She was taken to a local emergency room for evaluation. X?rays were taken of her spine (cervical, tho racie, and sacral} her lei! Homeros. C- scan of her head was taken. nothing was noted abnormal. The physician instructed her to take Motrin for the 1 few days and to wear a neck collar until she is evaluated by a neurosurgeon in two attachm?tolernted the procedure well and returned to the facilityI the same day. Her dl was losed head injury without a concussion. ?llers-up appointment is in the process of heigseheduled at this time. Date/'1' ime of iniury: November 03. 2014/ 30:25 AM Was the resident in a restraint/seclusion at time of iniunr? NO 000121 4/15/l0 Section 5. Report of a Death of Resident (The death of a resident. regardless of circumstances or causation, MUST be reported to all agencies listed above. including CMS Regional Office. Please submit Death Reporting Worksheet to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation, including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No[ if yes. check type: Restraint Seeiusion . Section 6. Definitions Race of resident is classified as W(White) B(Blacl<) H(Hispanic) 0(Other. including Native Amen. Asian) Restrajnrmeans a ?personal restraint? a ?mechanical restraint? or ?drug used as a restraint.? Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that he/she cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that (1) is administered to manage a resident?s behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident?s freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. Emission means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial hematomas. internal organ injuries. head injuries and sprains/suspected bone injury iforay is ordered. Suicide Arte-mgr is an act that demonstrates some minimal non-zero intent to die as a result of the act' This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act.I The act under this definition includes implementing any steps to carry out: a plan (Le. putting a rope around one?s neck).I A suicide attempt also includes attention-seeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. Inc. in collaboration with American Association ofSuicidology; Revised October 2008. citing "Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner. Brent. 0.: Lucas (3.: Gould. M.: Stanley. Brown. Fisher, Zelacny. Burke. Oquendo. Mann. 2 Attempt De?nition 3 Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development, Inc. in collaboration with American Association of Suicidology; Revised October 2008. monitor 3 of 4 4115/10 injury. Therefore. even if no physical injury occurs during a suicide attempt, it should still be reported as a serious occumnce, per the federal reporting regulations. 00012?? 4 of4 6,3940% 67 HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-4034 FAX 205-338-4024 FACSIMILE TRANSMITTAL SHEET TO: FROM: Glon'a De?m'o Holloway Wanda Jordan EN. Dun; DHR State ofAfabama 11-18-14 mmum En.- TOTAL moa?acss INCLUDING coma: 334~353-2693 5 334-242-8177 The contained in this facsimile- mung: is legally pain'ltged and m?dcnual inform-don, which in only far the use of the individuai or vanity unused shun. Ifthv: 51::de- ul' m5: mg: is no: :11: launder] rccipitul. you In: humbly nau'?ud than any we. diaeemimu?on, dilldbuliou or reproduction of this mean-El: in ninth? mohibitcd. Ifwu hive remind this menu: in arm, alum nod?' and? immldiaufv. in 6869 FIFTH AVENUE SOUTH BIRMINGHAM. ALABAMA. 35212 000124 Hill Crest Behavioral Health Services 6869 Avenue South Birmingham, Alabama 35212 Date of Report: Novemyeg 2014 of Incidents: ngmhe]; 1,6, 2014119,}: Egg Group Home: Higgn? Hill Grog: Home Report Received: mm ??uent Name_ Date of Birth. Name of Gun Race: gnucasian Gender: Mai; Diagnosis: Disorder L?esident Name? Date of Birth:? Race: 81351; Gender: ale Diagnosis: imgulsg 2mm: _ond In a physical altercation on Sunday November - admitted he punched first becauSe he was laughing at him. _stoted he had told -to stop. but ho kept laughing which lead to both tl'l wiring punches. Staff separated the residents. Upon assessment the nurse noted that had a bruise to the left eye, no visual problems and a red mark to his neck, no broken osmment indicated a small hematolno on his forehead. No treatment other than ?rst aid was required for both residents. No further compilations at this time from the Incident. Director of Risk Management 000125 6r a1 . Hill 6 If rest Behavioral Health Services 6869 Avenue South Birmingham, Alabama 35212 Date of Report: November 13. 2014 Date/rime of Incidents: November-15, 201d?11=as AM Group Home: gessemer guys Groug Home Report Received: November 11,2915 R668: 8_iack Gender: Male Diagnosis: Conduct Disarder Description of incident; -was admitted to Our Bessemer Boys Group Home on Friday' November 14. 2014. He was doing fine, no problems. The morning of November when staff exited the group home, - followed her. The staff instructed him to go back inside the group home, he refused. He informed the staff "can?t stay in a place like this anymore" alkod across the street, to the park across from the swap home. Staff tried to encourage him to return, however he kept walking. The local ithln five minutes. Staff processed with him and explained the police was notified and returned i i-?OHSEQI-iences for his actions. ?stated he understood and apologized for walking away. Then he informed staff,? can't remain at thi acement" and he walked away again. The local police was notified again of his decrement.? returned within One hour. He was assessed by staff, no injuries were ?uted, no known criminal activity occurred during his elopements. WM 419% Wanda .lorda RN Director of Risk Management 000126 r7 p; Hill Crest Behavioral Health Services 6869 Avenue South Birmingham, Alabama 35212 Date of Report: November 18. 3014 Date/Time of incidents: (integer 20, 20143: 8:45 AM Group Home: Higdon Hill Greug Home Report Received: Octobeg 3E: 2014 Resident Name- Name of Guardian: Date of Birth: Race: Caucgsian Gender: Male Diagnosis: Cguguc; Disorder Deu?gtign of Incident: -lnformed staff he had tried to self tattoo his thighs. UpOn assessment the nurse noted 4 super?cial cuts to his right thigh, red, no drainage, and no sign of infection or swelling. The cuts were one inch or less. denied having any pain or discomfort. as also assessed by our CRNP, he was placed on an antibiotic as a prephviactic measure. had no further complications from this incident. The group home nurse notified his DHR worker the day of the incident. Wanda Jordan RN Director of Risk Management 000127 (5?6 (#151520 Vi 7? Hill Crest Behavioral Health Services 6859 5"1 Avenue South Birmingham, Alabama 35212 Date of Report: November 18. 201,5 Date/Time of incidents: November 16. PM Group Home: ?igdog Lilli Group_ Home Report Received: November 17: 2014 Resident Name_ Date of Birth:? Race: Caucasian Gender: Female Diagnosis: Mood Disorder .2_.Resident Name:? Date of Birth:? Name oqua Race: Black Gender: Female Diagnosis: Conduct Nm?eoquan? Date of Birth: Race; Black Gender: Female Diagnosis: Conduct Dlgorder gescrigtiog of Incident: The afternoon of Sunday November staff that she had pierce her own left ear and the right ear of both -and All three residents stated it was agreed that would pierce their ears. Upon assessment of all three residents, the staff noted that there was redness, no sign of infection, no drainage or bleeding at the site of the piercing. All three residents denied any pain or discomfort. Their physician was noti?ed of this incident, who Instructed the staff to clean the area and apply Neosporin ointment if any broken skin occurs. At this time, no further treatment has been required. Wanda Jordan RN Director of Risk Management 000128 m; iH Derico, Gloria From: Jordan, Wanda Sent: Wednesday. November 19. 2014 3:24 PM To: DH R_PSY21Report; psy21report?ad3p.ua.edu Subject: 21 Serious Reports.14. MCD Attachments: 21 Serious Reports.14. MCD.docx Wanda Jordan RN Director of Risk Management [ill Crest Behavioral Health Services 6869 Fifth Avenue South Birmingham, Alabama 35212 Of?ce 205~838-4034 Fax 205-838-4024 Ul is of Delaware. Inc. Con?dentiality Notice: This e-mail message. including any attachments. is for the sole use of the intended rceipicnlt?s) and may contain con?dential and privileged information. Any unauthorized review. use. disclosure or distribution 01' lhis information is prohibited. and may be punishable by lam. ll' this was sent to you in error. please notil?y the sender by reply e-mail and destroy all copies ol'the original message. 0001 29 v. 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 C.F.R. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama?s Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protecrion and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be sub_mitted no later than the close ofJbusiness the next business day after a serious occurrence. Serious occurrences under the Act that must be reported include a resident's death (for any reason), serious injury (for any reason) to a resident as defined in 42 CPR. 9483.352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence. scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident?s record. In addition, please refer to the required ?Death Reporting Worksheet - that must be submitted to the Centers for Medicare and Medicaid Services (C MS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 404662-7435. Document in the resident's record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted November 17. 2014 25 Report of Serious Occurrence has been placed in resident record November 19, 2014 Centers for Medicare and Alabama Department of Alabama Disabilities Alabama Medicaid Agency Human Resources Advocacy Program Medicaid Services Regional Office Ms. Susan Ward. Dir. Of?ce of ADAP Executive Director Ms. Jan Sticka,, ngram Resource University of Alabama Manager Mental Health S. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa, AL 35487- Montgomery. Alabama 36104 Efas?f?om?E?-?n PO BOX 304000 0395 and fax to CMS Montgomery, AL 36130 334-353-4151 FAX 404-562-7435 334-353-2309 (fax) @121rapgrt?medicaidalabamagov 0001 3931: I or: Section 1. Facility Information: 21 Facility Program name: Hill Crest Behavioral Health. C?Team Unit Street Address/City/Zip 6869 Avenue South Birmingham, Alabama 35212 Telephone/Fax 205?838?4034} 8384024 fax Name/Title of person completing report: Wanda lordan RN Director of Risk Management Section 2. Resident Information: Date of this report: November 19. 2014 Date/Time of serious occurrence: November 17". 2014/ EDD PM Resident full name- Resident date of birth: Name??tddress 'an: Race: I Gender: Female Dx: Bipolar Disorder NOS Section 3. Report of a Serious iniurv to a Resident: Datefl'ime of iniury: Was the resident in a restraintr'seclusion at time of iniur? Eyes. check type: Restraint l] Seclusion 1 Section 4. Report of a Suicide Attem a Resident: On November lath?reported to the nurse while she was in the shower the night before, she had dran an undetermined amount of White Rain Hair Conditioner". She stated she drank it because she was upsetfangry at a peer. She denied any vomiting or nausea last night or this morning (ll-4844 The nurse noted she did not have display any respiratory distress. Her physician was notified and he placed her on suicide/safety precautions. Also her showers must be monitored along with the amount of shampoo/conditioner given. The nurse also called Alabama Poison Control, per their staff ?the patient should be okay. Due to her not having any nausea/vomiting and she was able to eat her breakfast?. All items that she could use to harm herself were removed from her room and her hygiene box. No further complications at this time. DatefTirne: November 17, PM 000131 1? Section 5. Report of a Death of Resident (The death of a resident regardless of circumstances or causation MUST be reported to all agencies listed above. including CMS Regional Office Please submit Death Reporting Worksheet to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/1' ime of dcath Was the resident in restraints or seclusion at time of death? Yes No if yes check type. Restraint Seclusion Section 6. Definitions Race of resident is classified as W(White) B(Blacl<) H(Hispanic) O(Other. including Native Amen. Asian) Restraint means a ?personal restraint" a ?mechanical restraint" or ?drug used as a restraint." Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident's body that hc/she cannot easily remove that restricts freedom of movement or normal access to hisfher body. Drug use as restraint means any drug that is administered to manage a resident?s behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricting the resident's freedom of movement; and (3) is not a standard treatment for the resident's medical or condition. Sit-closing means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious Injury means any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor. osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor's private office through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: bums. lacerations requiring sutures. bone fracture. substantial hematomas. internal organ injuries. head injuries and sprains/suspected bone injury ivaray is ordered. Suicide Attempt is an act that demonstrates some minimal non'zero intent to die as a result of the act. This intent can be inferred if the act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act. The act under this definition includes implementing any steps to early out a plan putting a rope around one neck). A suicide atternpt also includes attentionrseeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting . Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education DeveloPment. Inc. in collaboration with American Association of Suicidology: Revised October 2008. citing "Columbia Suicide-Severity Rating Scale (C SSRS) developed by Posncr. Brent. 0.: Lucas C.: Gould. Stanley. Brown. Fisher. Burke HOquendo M4 Mann.l.. :hnp: waw fda ppt#936. l2 .Suicidc Attempt De?nition and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals: Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association of Suicidology: Revised October 2008. 0001 331ge of 4 injury. Therefore, even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence. per the federal reporting regulations. 00013;:134 of4 8+3; cm" HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838~4034 FAX 205?838-4024 FACSIMILE TRANSMITTAL SHEET TO: FROM: Gloria De?n'co Holloway Wanda Jurdan FLN. COMPANY: man: DHR State of?iabama 11?19?14 FAX NUMBER: TOTAL NO OF PAGES INCLUDING COVER: 3344353 -2693 2 PHONE NUMBER: 334?242-8177 The information contained in this facsimile mung: is lcgally and con?dential information. which is intended only for the use of use individual 0r entity named above. If radar of thin message is not the intcrII-?led recipient, you are uni?ed that any use, dissemination, distribution or tcpnodumian of this message is attic?v prohibited. lfvnu have received this menu: in alum: the uncle: immudiatelw El: 6869 FIFTH AVENUE SOUTH. BIRMINGHAM, ALABAMA 35212 0001 34 Hill Crest Behavioral Health Services 6869 5?'1 Avenue South Birmingham, Alabama 35212 Date of iieportLijouemhgg-IB. 2043? Date/Time of Incidents: November 13. 2014! 12:30 PM Group Hernia: Bessemer Group Harrie.-.) Report Received: ?uvember 19I 201d Renew Gender: Male Diagnosis: anduet Disorder Descrigtion of incident: -and his peers were at our main cam us for lunch. Staff was getting the residents on the van to them *0 BTOUP home when ion down the street. The staff tried to apprehend him but was unsuccessfuit A police report was ?led with Birmingham Police and his DHR werker was noti?ed. Staff received a call from -uncie who stated ?35 at his house. Staff requested the uncle to return him back to the group home. returned within six hours after his elopement, no injuries were noted and no known criminal activity occurred during his eiopement. His physician recommended that - be admitted to our acute adolescent unit for stabilization when a bed is available. Group Home Director] Program Director has instructed staff to monitor-closely for his safety and to prevent another elopement. v?w?lf Wanda Jordan Fi? Direct0r of Risk Management 0001 35 A Lk ?55 a. HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-4034 FAX 205-838-4024 PACSIMILE TRANSMITTAL SHEET TO: FROM: Gloria Dc??co Holloway Wanda Jordan R.N. cor-rum? DATE: DHR State of Alabama 12-16-14 FAX NUMBER: TOTAL on no es coves; 334-353-2693 2 wow; NUMBER: 334-242-8177 The information wanincd in this facsirniic message is legally privileged and cn??dm?ll which ?5 intended only for the us: of individual or entity numcd above. 111: reader ofthia manage il the intended recipient. you are noti?ed than my nun. dissemination, disuibu?ou ?it-Hurt ill sit-ind? prohibited. vaou have remind this menace in error. ulna: nmi? the nudzr 6869 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000136 Hill Crest Behavioral Health Services 5359 Avenue South Alabama 35212 Date of Date/Time of Incidents: 15 3:30 Group Home: ?lli Group; [1qu Report Received: 16.11113 Resident?s Name: _Date of Birth:- Name of Guardian: Race: M113 Gender: Femalg Dlagnosls: Mm 9f in?dent: while-was at a physician's Ippolntment, she was scheduled to have blood durum-sired the physician's nurse if she use the bathroom. Upon leaving the bathroom-an out uftho office before staff could stop her. l-Iigdon Hill stuff Immediately notified the group home of decrement. A police report was filed with the Birmingham pallce. Her worker was also noti?ed of the elopement and she voiced understanding. Today- December her DHR 1mnkor noti?ed the group home that -wn safe and with her family. Her worker stated she would go to home tamurrow and encourage her to return to the group home. WI ndaiordan RN Director of Risk Management 0001 37 WW HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-4034 FAX 205-838-4024 _vrv FACSIMILE TRANSMITTAL SHEET To: Gloria Dc'rico Holloway Wanda Jordan R.N. commv: mm DHR Sum: ofAlabamz 12-10-14 nx mm. NO. or Mass menunma comm 334-353~2693 3 mm HUME an. 334242617"? The contained in this facsimile musing: is legally privileged and con?dential inform-liom which ll incendcd only for :11: not at individual or unity named above. If render of this mung: in mat the intruded rccipicnl, you an: hemby nuii?ud that any me, diuunminau'ou. distribution or tepmducliop afthi's mung?: is uricdv mi?bimd. If Iran have received this mnnmu in cursor. uleue noll?r the send-u mun-dutch. A . m- q- 6369 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000138 Hill Crest Behavioral Health Services 6869 5'h Avenue South Birmingham, Alabama 35212 Date of Report: Decemhgr 19, 2:114 Date/Time of Incidents: WM Group Home: ?lgdon [11? 5193'; Home Report Received: December 10. 2919 Resident Na me- Race; lleclc Gender: Male Diagnosis: Disorder Den?g?gn ul' lncid?t: -ren out of the group home while staff and peers were returning with breakfast trays from the cafeteria .He pushed pass them as they were coming through the exterior clear. Staff tried to stop him but was unsuccessful. Additional staff helped to searched for him and located him twa blocks from the group home. Staff encouraged him to return to the group home which he did. -was assessed by the nurse who "Wu nu Injuries. His physician pieced him on Precautions for the next week. stated he run because he felt he was seeped-up. The nurse process with him and instructed he should speak with his therapist or staff If he felt he needed to elepe. He stated he would if he ?wents to run?. Director of Risk Management 0001 39 Hill Crest Behavioral Health Services 6869 5?h Avenue South Birmingham, Alabama 35212 Date of Renew Date/Time of Incidents: Deoemhn: g. gnu: 1mg EM 1. Group Home: Hi?on Hill Group Home Report Received: Retident Name- Date of Birth- Race; White Gender: ample Diagnosis: gm 2. Group Home: gimp Home Resident's Name: Race: Bigok Gendar: Male Diagnosis: Bipolar Wot: -Ind -were eiiuwed to go Into a sandwich shop by themselves while our staff member remained In the van. Whiie waiting for their food. the residents heel hinted each other end made the decision to have the shop's bathroom. Idmitted the performer! oral out or- and then he penetrated her vagina. Then both residents some out. picked up their food and returned to the van..- con?med this information. This incident was reported to staff Friday evening.- is on birth control. Neither resident be: hisl??f dleense. Their Dt-ill workers were noti?ed Monday morning by ngdon Hill therapist. Disciplinary action was taken against the suit member. Wanda Jordon RN Director, of Risk Management 0001 40 jg HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-4034 FAX 205-838-4024 FACSI MILE TRANSMITTAL SHEET TO: FROM: Gloria DE?dco Holloway Wanda Jordan R.N. COMPANY: DATE: Slate of Alabama 12?15?14 PAX NUMBER: TOTAL PAGES mcwomc comm 33435343693 2 moms NUMBER: A .. 334242-81 77 The information containcd' Il'l thiu facsimile mciugc is legally privileged md Con?dential infatmarion, which Is intended only for the Use of the individual or entity named show: If llu?: of this mung: it not the intended recipient, yOu are hereby noti?ed that any use. dissemination. distribution or mpmducdon of thin message in ericIlv prohibited. If vou haw.- teach. ed this meant: In :rmr. ulna: nodfv the under immediuttlv. 6869 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000141 Hill Crest Behavioral Health Services 5359 Avenue South Birmingham, Alabama 35212 Date of Report: December 15. 1915 Date/Time of Incidents: WM Group Home: Emile Home Report Received: rig-Lemar 15, ?14 Resident?s Name:? _Date of am? Race: Biagls Gender: Male Diagnosis: tending Disorder 931W: During rounds, staff noticed that -was nor In the group home. staff searched lar him Inside the group home We: not able to locate hlm. Staff went outside and noticed he um walking toward the group home by himself. .3: absent from the group home 12-15 minutes. Staff questioned where he had been, he stated "left to so to the store". Staff found he had a honey bun and a pack of cigarettes. Staff confiscated the cigarettes and -n5 placed on house restrictions. Staff informed him he could not leave the group home without stall, he verbalized understanding. His DHii worker was noti?ed of the Incident. No Injuries occurred during his elopement. Migr?u air Wanda Jordan Director of Risk Management 0001 42 (a Hill Crest Behavioral Health Services Risk Management Dept. 6669 5" Avenue South Birmingham. AL, 35212 205-333-4034 FAX: 838-4024 Fax To: Gloria Holloway From: Denise Jones. RN, JD.DRM Fat: 334-353-2593 Pages: (Wading cover sheet) 2 Phone: 334-242-8177 Date: 12022015 Rn: Elopernent cc: . .u Urgent For Review El Please Comment El len Reply Manse memk ?mn?vu/qu (7M /0I?u/na? 0001 43 Hill Crest Health Services 0869 5?1 Awnuo South Birmingham, Alabama 35212 Dam of meow Date/Time of WW Gmup Home: ?gmgr Emu! Home Report Received: November 30. 10;: Resident's Name: of Birth-? Name of Guardian: Race: 9135; Gender; Mill Diagnosis: Disruptive Dohavior Disorder ?m?lg of Incident: resident at Bessemer Group Home eloped on 11/23/2015 at nopro?motoiv 7:23 PM. While returning to the your: homo from an outing, he became aggressive with a peer In the van, refused and to tie-escalate. When the van approached a mill: lung-got out. Once outside he mean threatening comments and more: toward staff. He reiusad to get but in the van; turning and walking across the stunt. Bessemer Polite Dept. noti?ed, can nu Inher? noti?ed per Program Manager. At 9:00 PM on 1130/2015- retumod to the Bessemer Group Home. His eiopernent was for approximately 2 3i hours. There were no reportod injuries and no known criminal activity was reported. Julia Denise Jones, RN, JD, DRM 3?5 70/ Director of Risk Management Hill Crest Behavioral Health 6869 Fifth Avenue South Birmingham, Alabaml 35212 205-833-9000 205-838-4034 Risk Management Office 205-338-4024 Risk Management Office Fax HAW 0001 44 law Hill Crest Behavioral Health Services Risk Management Dept. 6869 5m Avenue South AL. 35212 205-838-4034 FAX: 338?4024 Fax To: Gloria Holloway Flam: Denise Jones. RN, Fax: 334?353?2693 Pages: (including covur sheet) 2 more: 334-242-81?? Balm Re: lnddent elopemenl Urgent For Raview [3 Please Comment Please newly El Please Recycle WlShan you and all of your staff a very Happy and Blessed 0001 45 Croat Bohlvloral Health Services 6869 5" Avenue South Alabama 35212 Date of Datemma of Incidents: MM Group Home: William Report Received: mm Resident?s Manic? Date of Birth?? Race: Gender: Diagnosis: mm on ?waa on an outing on Sunday evening. Nmbor 22, 2015 will: staff and peers who she eloped from the business mablishrnent at approximately 3:45 PM. Elopernant policies were followed. Police reports warn filed. DHR um noti?ed. Our will was unable to locate her. At approximately 9:30 PM, Irondale Polio. Dam. returned her to the Group home, unharmed. pimiul unchanged and she had not been involved in any ulmlnol activity. Julia Denise Jones, EN. 10. DRM Director of Risk Management Hill Crest Behavioral Health 6869 Fifth Avenue South Birmingham, Alabama 35212 2054333000 205438-4034 Risk Management Office 205-838-4024 Risk Management Of?ce Fax 0001 46 Hill Crest Behavioral Health Services 6869 5"1 Avenue South . Birmingham, AL. 35212 Management Dent- 205-838-4034 FAX: 838-4024 Fax To: Gloria Holloway From: Denise Jones, RN. Fax: 334-353-2693 Pages: (including cover sheet) 2 Phone: 334-242-3177 mate: 1112512015 Re: arrest cc: Urgent For Revidrw El Please Comment Plenum Reply Pleas- lumydo you and all of your staff a very Happy and Blessed Thanksgiving! 0001 47 Hill Crest Behavioral Health Services 6869 5" Avenue South Birmingham. Alabama 35112 Date of Date?lmo of Incidents: WM Group Home: mm Report Received: 3mm Resident?s Name: of Birth?? Name of Guardian: Race: GenderiJ?? Diagnosis: Attention Deficit Hyperactivity Disorder Bataan?Gnu at approxitnatelv 6:30 PM throat-hing stuff with bodily lnlury or to have his Milt) member ln?ict this injury to staff. At this time he was sumo, iv: and refused to redirect. The police were called and a report filed. Cue number One hour later at 1:30 PM he was demanding to use the phone. when adviuod he could not It that time, be begun to destroy tho Group Home a throwln the file cabinet, thalamus star" with phvtiml harm. The police were tailed again momma: tramportetl to jail. bit! was made more on 11/22/1015 per Program Manager. Julia Oenlse Jones. RN. JD. DEM WW 3241,15, Director of Risk Management Hill Crest Behavioral Health 6369 Fifth Avenue South Birmingham, Alabama 35212 205-833-9000 205-838-4034 Risk Management Office 205-838-4024 Risk Management Of?to Fax 000148 5%ng Derico, Gloria From: Jordan, Wanda Sent: Monday. October 19. 2015 8:36 AM To: psyereport@adap.ua.edu Subject: 21 Serious Occurrence Reporting MCD Attachments: 21 Serious Occurrence Reporting MCD.docx See attached Wanda Jordan RN Asst. Director ofNursing Hill Crest Behavioral Health Services i330? Fifth Avenue South Birmingham. Alabama 3521?. Of?ce 205-838?2076 Fax 205-776-6463 UHS oi? Delaware. inc. Con?dentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain con?dential and privileged information. Any unauthorized review, use, disclosure or distribution of this information is prohibited. and may be punishable by law. if this was sent to you in error, please notify the sender by reply e-mail and destroy all copies of the original message. 000149 4/l5l10 21 Serious Occurrence Reporting Form This reporting form is to be used by residential treatment facilities providing inpatient services for individuals under the age of 21 21), as required in 42 CPR. 483.374 and which have a provider agreement with Alabama Department of Human Resources (DHR). Each 21 facility is required to report any and all serious occurrences to: Alabama's Medicaid Agency; Alabama Disabilities Advocacy Program (ADAP), the state designated Protection and Advocacy system; DHR, the licensing agency; and the Legal Guardian of the resident. This report must be submitted no later than the close of business the next business (flag)!r ajt_er a serious gecurrence. Serious occurrences under the Act that must be reported include a resident's death (for any reason), serious injury (for any reason) to a resident as defined in 42 CPR $483352, or suicide attempt by a resident. See Section 6 for definitions. Please print or type the requested information below. For each serious occurrence, scan and email copies of this form to each of the three agencies identified in the boxes below and enter one copy in the resident's record. In addition, please refer to the required ?Death Reporting Worksheet that must be submitted to the Centers for Medicare and Medicaid Services (CMS) regional office before close of business the next business day after the resident?s death (CMS regional office notification is only required for deaths). Reports to the CMS regional office may be submitted via fax at 4045627435. Document in the resident?s record that a death was also reported to the CMS Regional Office. Please check the following when completed and include date: Parent and/or legal guardian has been contacted: October 15. 2015 Report of Serious Occurrence has been placed in resident record October 16. 2015 Alabama Department of Alabama Disabilities Alabama Medicaid Agency Centers for Medicare and Human Resources Advocacy Program Medlcald Services Regional Of?ce Ms. Susan Ward. Dir. Of?ce of ADAP Executive Director Ms. Karen Smith. Program Resource University of Alabama Manager Mental Health 8. Gordon Persons Building Box 870395 501 Dexter Avenue 50 Ripley Street Tuscaloosa, AL 35437-0395 Montgomery, Alabama 36104 PO BOX 304000 and fax to CMS Montgomery, AL 36130 334-242-1653 205-348-4928 334-353-4945 FAX 404-562-7435 95221 regg?gdh r.alabama.gog [15121 rmri?adlg. emetic Page 1 OH 0001 50 I . Section I. Facility information: 21 Facility Program name: Hill Crest Behavioral Health Services Street Address/City/Zip 6869 5'1' Avenue South Birmingham, Alabama 35212 Telephone/Fax 205:8384034 8384024 fax Name/Title of person completing report: Wanda lordan RN Director of Risk Management Section 2. Resident Information: Date of this report October 16 2015 Date/Time of serious occurrence: October 15, 20151835 AM Resident full name_ Reside - Resident race: Resident gender: Male X) Female Resident disability/diagnosis: Bipolar Disorder Section 3. Report of a Serious Injury to a Resident: -became aggressive, our on control, verbally threatened physical harm toward staff and selfihann. He refused re?directs from staff. For his safety, he was in a 211mm physical restraint. He was restrained for a rural of five minutes. Upon assessment Homplained of left arm pain. No visible injury (1. Physician notified, an Xaray was orde . any results indicated a Fracture left humerus. was sent to a local eme department for evaluation/treatment. The emergency physician placed his left arm in a splint. returned to the facility the same evening. He is to have a follow-up appointment in one week wit an orthopedic. Date/Time of serious injury October 15. 2015! 8:15 AM Was the resident In restraints or seclusion at time of serious in'u Yes No If yes, check tyne: Restraint IX 1 Secluslon .. l' Section 4. Report of a Suicide Attemo lav a Resident. . Date/Time of incident: Was the resident in restraints or seclusion at time of suicide attempt? Yes NO If yes.check type: Restraint[ Seclusion[ 000151 4/15/10 .- . Section 5. Report of a Death of Resident (The death of a resident, regardless of circumstances or causation. MUST be reported to all agencies listed above. including CMS Regional Office. Please submit Death Reportinit Worksheet to CMS in case of death Description of the reported immediate cause of death and the events preceding death (attach additional documentation. including incident reports and medical reports): Date/Time of death Was the resident in restraints or seclusion at time of death? Yes No lfyes.check type: Restraint[ Seclusion[ Section 6. Definitions Race of resident is classified as W(White) B(Black) H(Hispanic) O(Other. including Native Amer. Asian) Restraint means a ?personal restraint" a ?mechanical restraint" or ?drug used as a restraint.? Personal restraint means the application of physical force without the use of any device. for the purpose of restricting the free movement of a resident's body. This does not include brie?y holding without undue force in order to calm or comfort resident. or holding a resident?s hand to safely escort from one area to another. Mechanical restraint means any device attached or adjacent to the resident?s body that he/she cannot easily remove that restricts freedom of movement or normal access to his/her body. Drug use as restraint means any drug that is administered to manage a resident?s behavior in a way that reduces the safety risk to the resident or others; (2) has the temporary effect of restricring the resident's freedom of movement; and (3) is not a standard treatment for the resident?s medical or condition. Seciusr'mr means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. Serious ingurymeans any significant impairment of the physical condition of the resident requiring medical treatment by a licensed medical doctor, osteopath. podiatrist. dentist. physician's assistant. or nurse practitioner and the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at the doctor?s private off ice through treatment at the emergency room of a general acute care hospital. Serious injuries do not include injuries that require only the administration of minor first aid. Examples of serious injuries include. but are not limited to: burns. lacerations requiring sutures. bone fracture. substantial hemaromas. internal organ injuries. head injuries and sprains/suspected bone injury ifx'ray is ordered. Suicide Attempt is an act that demonstrates some minimal nonvzero intent to die as a result of the act.? This intent can be inferred ifthe act could be viewed as potentially lethal by someone or based on the circumstances of the incident. even if no harm actually resulted from the act} The act under this definition includes implementing any steps to carry out a plan (Le. putting a rope around one?s neckll A suicide attempt also includes attention'seeking conduct if the conduct can be viewed as potentially lethal by someone or based on the circumstances of the event. despite the lack of a resulting injury. Therefore. even if no physical injury occurs during a suicide attempt. it should still be reported as a serious occurrence. per the federal reporting regulations. Assessing and Managing Suicide Risk'Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center. Education Development. inc. in collaboration with American Association of Suicidoiogy; Revised October 2008. citing ?Columbia Suicide-Severity Rating Scale (C-SSRS) developed by Posner. Brent, Lucas Gould. Stanley. Brown. Fisher. Zeiazny. Burke. Oquendo. Mann, 1 3 Attempt Definition ?Assessing and Managing Suicide Risk-Core competencies for University and College Mental Health Professionals; Suicide Prevention Resource Center, Education Development. Inc. in collaboration with American Association of Suicidology; Revrsed I ber 2008. Page 3 of] 0001 52 #5 WK HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-858-4034 FAX 205-838-4024 FACSIMILE TRANSMITTAL SHEET mom: - (310153 De'nico Holloway Kei McDaniel LPG commw mum: DHR State ofAhbama 9/16/15 FA?xu UMBER: Tom. no. or mess INCLUDING covsm 334-353?2693 HUMMER: 334-242-8177 inrmmadnn contained 111 thin facuimilc mung: ls legally privilugcd and information. Mich is intendcd only for lhl: use of individual or =11:in named above. 1! 111:: made: of this mew-saga Is no! the inlcudud twig-ism, yuu hereby noti?ed any we. diucmim?om :limi?budm ur u! this in Btri?lv nmhibimi. 11' van ham: ?mind this manual." in error. ?lms: notifv I11: send? imbedl?dv. 6869 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000153 Crest Behavioral Health Services 5369 Menu: South Birmingham, Alabama 35212 Date of Date?ime of Incld-nts: Wm Group Home: Report Received: Wm Resident's Name: of Birth Race: gm Gaunt-Lug]; Diagnosis: Q?gig?ug 9! incident: -wu admitted to tho Minimum acute unit from the Hammer group home due to agar-Hive behaviors towards sta? and peers and destructive hehwinrs. Thu determined th could ban-fit from an evaluation of his mediation regimen and possible vindication adjustment. Kai McDaniel LP: XW Director of Risk Managtment 0001 54 Hill Crest Behavioral Health Services 6869 5'll Avenue South Birmingham. Alabama 35212 Date 01' Datefi'ime of IncidentS: WW Group Home: thog Hill group HEW Report Received: Resident?s of Birth? llace: Will]! Gender; Female Diagnosis: lentil: I On September tit-vat dropped off It her work site for job training earlier that morning. When staff arrived at the work site at approximately to pick her up. they were informed that the resident bod cloaked in at mm and had clocked out at 9:15am, stating that she had 3 nick baby, heel to lento work for the day Hill Crest personnel were aware of the situation. Staff members wore intmmed that had used the phone and, following her phone cell. waited outside. Staff members were told that she altered the building between 10:00 and 10:30am and asked a Ito-worker if they could give her ride to a speci?c location. Upon taking her to the Iooetlon. the cit-worker observed that?croued the street and left the premises with a young male. When the provided Hill Crest mil with a description of the yams mole end the phone numbers the- had celled, this information was consistent with that of another resident who was on a Tho Hill Crest personnel contacted the local maturities and provided them with the address of the other resident. The police went to that eddroos and found -lhere. They removed her from the address and returned herto Hlli Crest. She beam agitated and essaultive, injuring two Hill Crest employees. Currently, she is on Assault, Set-ti, end Elopement precautions. Kel McDaniel WSW Director at Risk Monitoment 000155 2% 59/77 2056? 31M HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-335-4034 FAX 205-838-4024 FACSIMILE TRANSMITTAL SHEET I03 Gloria De?nlco Holloway Kel McDaniel LPG COMPANY: DATE: DHR State ofAJab-mm ?3le 5 w: NUMBER: TOTAL NO. or ?was mciunizx'c COVER: 334?353-2693 (51 HON 8 UMBER: 334-242-8177 Thu iufmmadnn contained in um; [awhile manage l; lugauy privileged and mn?dmliul infumluliua; which inundad Duff {or Ill-r. um: of in?fidu? or Emil lbuvc. If the remit: of thin message is not recipient, yuu an: hmby na??cd that my me. disminntion, diauibulion. or reproduction of thin mum: is suicllv arohibiml. 11? man have waived this manual: in max. no?fv the umdu huncdiutnlv. 6869 FIFTH AVENUE SOUTH BIRMINGHADI, ALABAMA 35212 000156 Hill Croat Behavioral Health Sewlces nos Avonuo South Alabama 35212 Date of Repo?W Date?ime of Incidents: Group Home: WM Roport Received: Aug d. 1015 1. Resldent?s cram- Race: mash Genderud?. Diagram: MW 1. Resident?s Name: Date of Birth- Raco: Black GendIerlg Diagnosis: a. Resldont's Name: of Birth? Namo of Guardian: Rice: my; Gender: Male Diagnosis: Wu MW ?elopod from the grow: homo aflor manual-m locks to the doors. Polloe and DHII worm wore notified. They war: may from tho group homo for approximately 20 minutu. They mound voluntarily to the group home. All mldonts won aloud on unit No known criminal or outer adverse octivity occurred tho mldorm were away from the group home. The look: were usnmd for vulnerabilities by ?le omiroumentol ?Moos mil and repaired. McDaniel LPC Director of Risk Minamoto-lent 000157 53/7/2395 HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-833-4034 FAX 205-838-4024 FACSIMILE TRANSMITTAL SHEET To: FROM. Gloria De?nico Holloway Keel McDaniel LPC COMPANY: was; DHR State of?labnma 3 I 511 5 FAX NUMBER: mm. NO. as mares mc?uaiwc covzm 334-353-2693 551 PHONE NUMBER: 334-242-8177 The infomuiun contained in 11135 famirn?e massage I: Inga-?y uud m?dcnliul information, which hunted on?y forth: nu: of 111:: individual or madly named abouc. Ifzh: nudu 1:1?:th musing-a is no! It?: inundcd Ndpitnt. yuu are hereby no??cd ch" my um, diiuminu??n. dilu-ibudon at mpmdunion of IE: mums: in uuiullv nmhibiwd. van have received this mum: in war. plum noti?' the with: humcdiatclv. 6869 FIFTH AVENUE SOUTH BIRMINGHAM: ALABAMA 353? 000158 Hill Crest Behavioral Health Services uses 5" Avenue South Birmingham, Alabama 35212 Date of Reponm?g Date/Time of Incidents: mm Group Home: Wham Report Received: 5 4 1915 1. Resident?s of Birth- Name of Guardian: Race: link Genderm: Diaamln MW 2. Resident's Name: Date of Birth? Race: Black GendeingJg Diagnosis: 3. Resident?s Name:? Date of Birth? Race: ?ask Gender: Male Diagnosis: cloned from the group home after manipulating locks to the doors. Police and Drill workers were notified. They were em from the group home for approximately 20 minutes. They maimed voluntarily to the group home. All three resident: were placed on mit restrictions. No known criminal or other adverse activity ems-red while the residents were away from the are up home. The locks were asserted for vulnerabilities by the environmental services staff and repaired. KalMcDanlel LPC Director of Risk Management 000159 .6 HILL CREST BEHJEVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-?034 FAX 205-838-4024 FACSIMILE TRANSMITTAL SHEET 1'0: new Gloria De?rico Holloway Kc! McDaniel COMPANY: DATE.- DHR Stat: of Alabama 7/ 7/ 15 m: Humm- row. NO. or macs mam-mm covam 334-353-2693 moxa woman: 334-242-8177 The Morml?on contalncd in thin Minn: mung: it and con?dan?sd ?lm-mum, which is handed only for the In: of 1hr. individual or mildly named above. If the 1mm of this massage no: the {Jamil recipient. yau hereby noti?ed that any use. diuumimtion, dimibu?an or lepnducdon a! this manual: is vuicdv Dmhibitcd. If Wu [1an waived thii amaze in war. please notil?v the under humedinmlv. 6869 AVENUE SOUTH BIRMINGHAM, ALABAMA 35212 000160 Hill Crest Behavioral Health Services 6869 59' Avenue South Birmingham, Alabama 35112 Data of napalm Date/Time of Incidents: WW Group Home: Report Received: mm Ruident?s Name: Date of Birth- Bace: ?les! 66169er Diaznosis: maximum: WM: through an open door ofthe group home as 5 mil member was entering. The ooilu and the resident's DHR worker were no?lied. The worker Indicated that the resident was possibly upset due to not being able to receive his family' I homo pm. The patient was away from thereon home for approximately 1 is hours and to the group home voluntarily, but escorted by police. No known criminli activity or other events oe?urrod or were coined by the resident during the time that he was away from the group home. lei McDaniel DC Director oi Risk Management 000161 Hill Crest Behavioral Health Service: 5369 5? Avenue South aiminghorn, Alabama 35212 Date of ?new Data/Time of Incidents: Wm Group Homem?mahome. mart Receiveduiiw Resident?s of Birth Race: Egg Gendeer Diagnosis: Wiggle; er dd . -vas in the process of completing his mined chore of mm outthe trash when he cloned from the group home premises. The police and the resident's worker were noti?ed. The patient was way from the group home for lI boom-returned to the group home volunta rllv. No known criminal activity or other odvem event: occurred or were caused try the resident during the time that ho we: may from the group home. Ive-ti consequences as a result of his behavior. lei McDaniel Director of lit: Monument 0001 62 Hill Crest Behavioral Health Service: my Avenue South Dinninghom, Alabama 3521.2 Date of Date/Time 0f Incidents: mm Group Home: We. Renort Received: mm manning-amm? Race: GenderLMQE Diagnosis: Wm WM: -nn through In open door 01' the group home I staff member was exiting. The police end the resident?s Dill worker were notified. The police rel-urine the resident to the group home on July 5, 2015 at epomlrnotoly 3:05pm. No known ulndnal activity or other adverse event: occurred or were caused by the resident during the time that he was away from ?re [mun heme. McDaniel LPC Director of Risk Management 0001 63 Hill Croat Blhoviorll Health Servlm sass Avenue South Birmingham, Alabama 35212 Date of Reportm Date/?me of IncidEnts: Group Home: Wm Report Rmivad: mam Rosidont's Name: __Dote of Binh Nome oquardlan: Ilia: not Diagnosis: WW MW: -waiked away from tho group homo while outside during mrutional puiod. The police and tho resident's Dita mortar were noti?ed. The resident was possibly upset duo to not being able to naive his family's consent for a homo pun. Tho patient was away from the group home for approxlmotniy ti hour. returned to tho group homo voluntarily at oppmimotoiy 'mspm. No known criminal activity or other ado-one events occurrod or worn caused in the raid-ht during the time that he um may from tho group home. Kel McDonlol Director of Risk Management 000164 56 or? HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-4034 FAX 205-838-4024 FACSIMILE TEANSMITTAL SHEET TD: FIOM: Glo?a De?rico Holloway Kai McDaniel LPG COMPANY: mm: DHR Smut: ofAlabama 6/5/15 Fax swam TOTAL NO. or mans c'ovn: 334?353-2693 3 PHONE mm?: 334?24181 77 The information numb-red In lid-1 fzmimil: Inca-Hugs: in Inga-?y privileged and m?dendal Inauguration, which in humid only for an: um: Infill: individual or entity named abova. Ifthc undo! ofdlh mung: is not humid yum an: hareby noti?cd any use, dune-minding, diudbu ?an o: Hpmduc?an of this minute: ls salad}- nml?hitei- Ifmu have waived li?'l manage in error. please no?fv man- Man-dim!? 6869 FIFTH AVENUE SOUTH BIRMINGHAM. ALABAMA 35212 000165 Crust Behavioral Hutu: Services 6869 5" Avenue South BirminghamAlabaml 35212 {15" Data of ReportLl?nLE-m Dar-mm: of Incidents: MW Granp Home= MW Rtport Received: mm 1. Resldant?s Name: Date of Birth? Name of Guardian: Inca: Dlanosls: 2. nosident's Nlma: Data of Birth- Macadam-? Race: ?lm: Diagnosis: a. Resident?s Name: _?_Dam of Birth? NameomerdIan: Race: glad: Gender; Male Diagnosiscum-d ma- Ind pants down, whlle the-hid his backt- and ms named In mum -mmd that-manual tum lam recanted his allegation. On May N15. chitin: ?ier-p? union, he alleged that he had bun rapid by Mn 15, 2015. Bath social workers war- noti?ed. The police war: noti?ed and pus-mu to the mm on my 19, 1015 u: ?lo a report. Per the puma: mun-?I am to room for a mluatlon. It has also been ordered th? for my annually dildll?. 000166 ADDENDUM: This Is an add-Mum to the was originally subml?ad on May 20. 2015. On 29. 1015, durlnl troulmont team manila.? Indicated that rounmm ?the group home had found him to hm when he was ?rst admin-d to the you! human-tilted that ill. Incident occurred the ?rst day that he was admitted to the group hum- on January 29, 2015.-? an hr a forensic interview on Wadi-many. June 10. 2015 at 1:00pm at th- House. Kai Dunllt Director of was: Management 0001 67 b?tzelg Q1 HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-4034 FAX 205-838-6024 FACSIMILE TRANSMITTAL SHEET TO: ROM: Giana De?rico Holloway Kai McDaniel 0054mm mm DHR State ofAIabnma 6/4/15 gunman: TOTAL. Nog- me as coma: 334-355-2693 mom: swam 334?242-8177 The Wan-union ?unwind in chi-I facsim?c montage in legally priv?cged and con?dential Enrol-madam which Ii inundcd only for the um: 01' ch: indi?tluul or entity named thaw. If the rcndar or this mung: In no: It: ?apical. yam bench-y norm-:11 that any dilumin?in?, distribu?un 0: mpwduaion uflhis amaze in wind?: nrohihiud. ?you haw rescind meme: in cum. ulnar? nodfv due under Walt?. 69 IFT AVE UE SOUTH Bl MINGHAM ALABAMA 35212 65 000168 Crest Behavioral Health unless 6859 5" Avenue Scuth Birmingham. Alabama 35212 Date of Report; lung 5, 3015 Date/Time of Incidents: mm Group Home: Riport Received: Rosldem?s of Birth? mme oquardlan:_? Moo: my]: Diagnosis: mm mm: mar Polio. arrived to the Hammer Group Home on ail/15 at 7:15 They informed group homo staff that a coil nhono had been located in the mldonoe through the oi a unortphona designed to locate lost! stoiori toll phones. Tho owner of the cell phone was able to sound an alarm and the all phone was discount! undor the resident?s bed. It was worminod that while on on outing to tho Firminahlm won on slams-mi stolon tho all phone from the peers locker room?Wu talk-n to Jail for receiving stolen property and related approxlmmiv on: hour later. The DI-lii Worker was noti?ed. It is unclear at this time if tho victim will ho pressing chm-s against Roi McDaniel Director of Risk Mowment 0001 69 Hill Crost Behavioral Health Services 6869 5?h manna South Birmingham, Allhama 35212 Date of Repo??M Date/Time of Incidents: Mm Group Report 1. Resldant's Name: - Date of Birth Race: mm Gender: Mm Diagnosls: 2. Resident's Name: Data of Birth .l mm Race: EIIEK Gender; Maig Diamsis: MW MW: On June 2, 2015, .are with the cur mldents and mil of the group hum, tar-paring to hoard the facility van to return ham the main hospital in Eastllitcta tin group home. at boardln; the van with the othor residents. ran away frant the group. inf! members followed the anti-nu and was this to catch up to -Ind request he ruturn to the group home, to which hit compiled. All Ippraprlna procedural; ware followed durl this incident and the local worlds: and the Bill! workm warn noti?td. Tho whamabouts of are unknown at this time. KelMcDInlel UK: Director of Risk Mlnalarmnt 000170 . 8-9132-26? HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-338-4034 FAX 205v838-4024 FACSIMILE TRANSMITTAL SHEET to: snow Gloria Dc?dm Holloway Kai LPG 50mm; mu: DER SumofAhbama 6/1/15 Fix wmu: 334-353-2693 PHONE NUMBER: 3154-2442-8177 N0. 01' INCLUDING COVER: IhiIan?nguilkzunypI-ENWMd 13::an fatten" aft}- mam wu?wumcdubw; Rwanda batman! you In hunky nud?cd on: any use, incubation. Wm: or a! Iln'l name 5! mink unwind. burn ?ocked this mum: in mm picn- nad?r Ill mar: Medium? 6&69 FIFTH AVENUE SOUTH BIRMINGHAM, ALABAHA 35212 000171 Hill Crest Behavioral Health Services 6859 Avenue South Birmingham, Alabama 35212 Data of Plenum] no 1 -2lJ in? Date/Time of Incidents: Mag 35, 2015! l?rd?am . a, Group Ho 6: Gregg Report Received: Mag 26. ms 1. Reside nt?s Name: Date of Birth Name of Guardian: Race: Black Gender: Male Diagnosis: gogduct Qiggrder 2. Resident?s Name: Date of Birt- Race: Blaclg Gender: Mal: Diagnosis: gondugg Disordg; gf Incident: On May 24, 2015, staff reported to the Program Manager of the Bessemer Group Home that- -had oloped from the property, but, eight minutes later, tho local authorltlus returned both of the residents to the group ho me. Staff followed all appropriate procedures during this incident and notifind the DHR workers.?were given consequenoes related to their behaviors. Kei McDaniel ch Director of Risk Management 000172 Wage/W6 HILL CREST BEHAVIORAL HEALTH SERVICES DIRECTOR OF RISK MANAGEMENT PHONE 205-838-4034 FAX 205~838~4024 PACSIMILE TRANSMITTAL SHEET 10? PROM: Gloria De?rico Holloway Wanda Jordan R.N. Elam: 'Hia: DI-IR State ofAlabm 3-02 5 15 FAX NUMBER: TOTAL PAGES COVER: 334?353-2693 PHONE 3154-2428177 T11: in?ammation cam-alum in mi; facsimile manage is legally privileged and m?dmd-l in?nnantion, which Ili intended only for the use own: individual or 13:16:? mam-ad shows. If the rend-u of this mung-s no! tht? you an: hue?y noti?ed till! my use, diascminu?on, diam'bu?on OK mpmduo??n of menu: is mica? prohibited than have received this menace in em. please notify the nude: lmmedmdv. 6869 FIFTH. AVENUE SOUTH BIRMINGHAM. ALABAMA 35312 0001 73 Hill Crest Behavioral Health Services 6869 Avenua,South Birmingham, Alabama 35212 Date of RepoW Date/Time of incidents: MW Group HOME: WW Report Received: MAME Resident's Name: Date of Birth? Race: My; Gender: Male Diagnosis: mm W: became met in the and punched a wall with his left hand. Upon assessment the nurse noted left hand was swollen, skin was Intact and he was able to open/closed his hand witlwut difficulty. -ompiainad with pain. a PEN medication was given for his pain. H's physician was noti?ed of the Incident; an x-ray was ordered for his left hand. Ill-ray revealed an old metacarpal fracture with a deformity Involving the proximal filth metacarpal, no acute fracture seen. There was a question of a chip fracture at the base of the fifth metacarpal, referred to an orthopedic. 1% and: Jarda RN Director of Risk Management 0001 74 5/6 3/99/ Crest Behavioral Health Services 6869 5'h Avenue South Birmingham, Alabama 35212 Date of ReporILMarch 25. 201,5 Date/Time of Incidents: March 20. 2015/ 6:00 PM Group Home: Bessemer Gmuo Home Report Received: March 23, 2015 1.Resident?s Name: Date of Birth? Race: Black Gender; Male Diagnosis: Conduct Disorder 2. Resident?s Name:_ Date of Birth:? Nameoreuardiam? Race: White Gender: Mai; Diagnosis: CondLIct Disorder Description ofjggident: -valked awayI from the group home without stai't?a permission. Before their elapement, both were in the laundry room.- stated he was showing-how to use the washing equipment. Per staff, the residents did not display any behaviors that would indicated they were planning to alone. A police report was ?led and the guardians were notified of the incident. The group home director was noti?ed on Tuesday March 24?" by that he had been located and questioned if -could return to the group home. is scheduled to be re- admitted to the Bessemer group home this afternoon. The whereabouts of-is stiil unknown at this time. Wang/rt 7M Wanda Jorda RN Director of Risk Management 000175