§ 29.29 Incident reporting procedures.

The commissioners of the office of mental health and the office for
people with developmental disabilities of the department shall establish
policies and uniform procedures for their respective offices for the
reporting, compilation, and analysis of incident reports. Incident
reports shall, for the purposes of this chapter, mean reports of
accidents and injuries affecting patient health and welfare at
facilities. These policies and procedures shall include but shall not be
limited to:

1. The establishment of a patient care and safety team at the facility
level which shall include but not be limited to a: physician, nurse,
social worker and therapy aide, to investigate and report to the
facility director on:

(i) suicides or attempted suicides;

(ii) violent behavior exhibited by either patients or employees;

(iii) frequency and severity of injuries incurred by either patients
or employees;

(iv) frequency and severity of injuries occurring on individual wards
or in buildings at such facility;

(v) patient leave without consent;

(vi) medication errors; and

(vii) recommendations for corrective actions in response to incident
reports to ensure the care and safety of all patients.

2. The establishment of cumulative record keeping of incident reports
which identifies patient and employee involvement.

3. A compilation of uniform and measurable information, first on a
facility basis, then on an office-wide basis, that will indicate where
the greatest number and types of incidents occur.

4. Each facility shall aggregate its data monthly for the director and
that aggregated information shall be submitted, at least semi-annually
to the commissioner of the office of mental health and to the
commissioner of the office for people with developmental disabilities.

5. The commissioners shall transmit a copy of any report received
pursuant to subdivision four of this section to the state commission on
quality of care and advocacy for persons with disabilities.