Were there previous episodes of choking? Was there a PONS for dysphagia/dementia/seizures?
Start or increase another medication that can cause constipation? Any predispositions? What were the diagnoses prior to this acute issue/illness? Did the person have any history of behaviors that may have affected staffs ability to identify symptoms of illness (individual reporting illness/shallow breathing for attention seeking purposes, etc.)? Identify the appropriate 1750b surrogate. Web(3) OPWDD shall verify that each person has a plan for protective oversight, based on an analysis of the person's need for same, and that such need has periodically, but at least convert pressure cooker whistles to minutes; toll roads owned by china food-stuffing, talking while eatingor rapid eating? Seizure? Were appointments attended per practitioners recommendations? When was the last lab work, check for medication levels? Was there bowel tracking? Were staff aware of the risks/ plan? Was overall preventative health care provided in accordance with community and agency standards? Was this well-defined and effective? Did staff follow plans in the non-traditional/community setting? What was the person's level of supervision?
Is it known whether the person lost consciousness prior to the fall?
When was his or her last EKG? Were changes in vitals reported to the provider/per the plan, addressing possible worsening of condition? WebProtective Oversight Assisted Living Facility (ALF) Shall mean any premises, other than a residential care facility, intermediate care facility, or skilled nursing care facility, that is WebFor residential habilitation services, the initial habilitation plan must be written within 60 days of the start of the habilitation service and forwarded to the Medicaid Service Coordinator
Future hospitalizations? Were plans and staff directions clear on how to manage such situations? Did the person require staff assistance to stand, to walk?
is gene dyrdek still alive. Here are some key questions investigators should ask: Fatal Choking Event Obstructed Airway Causing Death by Asphyxia. hb```%\@9V6]h
Had the person received sedative medication prior to the fall? Were staff involved trained? Was the plan clear? Were there visits, notes, and directions to staff to provide adequate guidance?
Did the person start a narcotic pain medication? Was there an order for Head of Bed (HOB) elevation? How and when was the acute issue identified? Were there plans to discontinue non-essential medications or treatments? DNR? Once this happens, multiple organs may quickly fail and the patient can die.
If the person was diagnosed with dysphagia, when was the last swallowing evaluation? Did staff follow orders/report as directed? Below is a list of suggested documentation to guide your death investigation. 665 0 obj
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Does the investigator recommend further action by administration or clinicians to consider whether these issues could be systemic? WebThe PPO (refer to Appendix C - form C.4) indicates all key activities that directly impact the health and welfare of the participant and clearly identifies the individual (s) responsible for Life-threatening sepsis causes the blood pressure to drop and the heart to weaken, leading to septic shock. Were appointments attended per practitioners recommendations? What were the prior diagnoses? Did it occur per practitioners recommendations?
Documentation related to the plan, if required. Were they followed or not? Was it communicated? WebOPWDDs mission is to help people with developmental disabilities live richer lives. endstream
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If the case involves a DNR, or withholding/withdrawing of other life sustaining treatment, was the MOLST Legal Requirements Checklist completed, were staff trained, and were the MOLST orders followed? %%EOF
Did the person have any history of seizures or other neurological disorder? Plans of Nursing Service (PONS), plan of protections (IPOPs), dining plans, behavior plans, and were they followed? Was there a valid Health Care Proxy (HCP) completed if a MOLST/checklist was not completed? Available? Was staff training provided on aspiration and signs and symptoms?
What is the pertinent staff training? Were appointments attended per practitioners recommendations? Training records (CPR, Plan of Nursing Services, Medication
When was the last dental appointment for an individual with a predisposed condition? Plan(s) of Nursing Service as applicable. Were there signs that nursing staff were actively engaged in the case? When was his or her last consultation with a cardiologist? Confirm the person's lack of capacity to make health care decisions.
If you are not familiar with the MOLST process please see here. What were the safeguards for safe dining e.g.
Was the person receiving any medications related to this diagnosis? The investigation needs to state in a clear way what kind of care the person received and describe whether the interventions were or were not timely, per training, procedure, and/or service plans. Did the choking occur off-site or in a nontraditional dining setting (e.g.
Contact Agency People With Developmental Disabilities, Office for Title Habilitation Specialist 2 Occupational Category Health Care, Human/Social Services Salary Grade 17 Bargaining Unit PS&T - Professional, Scientific, and Technical (PEF) Salary Range From $57984 to $73813 Annually Employment Type Full-Time Appointment Type Permanent What occurrence brought the person to the hospital? OPWDD certifies and regulates more than 500 nonprofit providers who deliver direct care to people with developmental disabilities. Did the person have a history of Pica? Did staff understand and follow dining/feeding requirements? What was the diagnosis at admission? OPWDD maintains a high standard for governance, fiscal and safety compliance practices. The best way to prepare for your survey or agency review is through good operational practices and ongoing self-assessment. What to do after your survey when deficiencies are identified and a plan of corrective action is needed
Previous episodes?
Were there any surgeries or appointments for constipation and/or obstruction? Were the medications given as ordered? Falls.
Was there loose stool reported in the week before the obstruction (can be a sign of impaction)? Who was the doctor/provider managing the illness?
Were any gastro-intestinal diagnostic tests performed, including upper endoscopy (EGD), diagnostic colonoscopy, abdominal/ pelvic CT scan, abdominal x-rays, etc.? Was the agency RN involved in communications? Were missed doses reviewed with the provider? Were the decisions in the person'sbest interest?
Was there evidence of MD or RN oversight of implementation? What was the latest prognosis?
Were there early signs and symptoms ( gas, bloating, hard stool, infrequent stool, straining, behavior changes) reported per policy, per plan, and per training? the person's clinical and support needs as identified through an OPWDD approved assessment (described in more detail in Assessments); the necessary and appropriate services and supports (paid and unpaid) that are based on the person's preferences and needs; What were the directions for calling a nurse?
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Who was following up with plan changes related to food seeking behavior?
Which doctor was coordinating the health care? If so, was it followed and documented? Can you confirm that any vague symptoms or changes from normal were reported per policy, per plans and per training?
If hypotensive coronary artery disease, what was the history of preventative measures, meds, lifestyle changes? What were the PONS in place at the time? On the agencys part?
Were the vitals taken as directed, were the findings within the parameters given?
Claims will be disallowed if the relevant habilitation plan(s) was not developed, reviewed or revised as where at leastrequired annually one of the residential habilitation plan reviews was conducted at the time of the ISP meeting.
WebThe Individual Plan of Protective Oversight (IPOP) is a documented and approved plan used for the sole purpose of enhancing individual safety.
What was the course of stay and progression of disease? Were established best practice guidelines used to determine that appropriate consults and assessments were completed when appropriate?
consistency, support, storage, positioning? What was the content of the MOLST order? Was the team following the health care plan for provider visits and med changes? Did staff decide this independently, or was it with nursing direction? Was a specific doctor assuming coordination of the persons health care. Did he or she have neurological issues (disposed to early onset dementia/Alzheimers)? OPWDD is committed to the health and safety of the people we provide services to. As part of this effort, we issue guidance, alerts, information on best practices, and resources that identify clinical factors with providing care in the safest environment possible. To stay up to date on Safety Alerts, please visit our Safety Alerts page. (x) Oversight, protective. Were vital signs taken after the fall (this may determine hypotension)?
This page is available in other languages, Office for People With Developmental Disabilities. Were the risks addressed? When was his or her last lab work (especially if acute event)? Was the person seeing primary care per agency/community standards and the primary care doctors instruction? Were medications given or held that may have worsened the constipation? Was it provided? Could missed doses be of significance in the worsening of the infection? Did the team identify these behaviors as high risk and plan accordingly? If so, what guidelines?
Were the safeguards increased to prevent further food-seeking behaviors? They are not diseases or causes of death, but rather circumstances. Were staff trained? Did a plan include identified ranges and were there any outliers? The death investigation is always the responsibility of the agency. Who reviewed the bowel records (MD, RN)? Life Plan/CFA and relevant associated plans. If the fall was not observed, did staff move the individual? 0
If give medication PRN is stated, were conditions/symptoms for administration clear and followed? Stop/reduce a bowel medication? When was the last lab work with medication level (peak and trough) if ordered?
Were appointments attended per practitioners recommendations?
Was there a known mechanical swallowing risk? Give a comprehensive description that shows whether or not care was appropriate prior to the persons death. What was the infection?
Was it related to a prior diagnosis? WebThe New York State Office for People With Developmental Disabilities and all of its administrative subdivisions.
Was there anything done or not done which would have accelerated death? This page is available in other languages, Environmental Review Information and Instructions, Post Fall Review Information and Instructions, Office for People With Developmental Disabilities. Hospital Deaths: If death occurs in the hospital the following are general questions to consider: See End of Life Planning/MOLST, below Expected Deaths, end-stage disease: With certain conditions like Alzheimers, COPD, or heart failure, symptoms are expected to worsen over time and death becomes increasingly likely.
As part of this effort, Other? Was there an emergency protocol for infrequent or status epilepsy? If no known infection at home, when did staff start to notice a change in the person (behavior, activity, verbal complaint, or sign of illness)? Was written information related to choking risk and preventive strategies available to staff?
Please visit the Choking Initiative webpage.
Was it realistic given other staff duties? When was the last neurology appointment? Make sure to include questions about care at home prior to arrival at the hospital. Not all documents may be relevant to your investigation. Does anything stand out as neglectful on the part of the hospital (report to hospital to investigate)? When was the last consultation? Were the plans followed? Did the person receive any blood thinners (if GI bleed)? Was there a nursing care plan regarding this diagnosis? It clearly enlists the key activities that
Was the PONS followed? Last annual physical, blood work, last consults for cardiology, neurology, gastroenterology, last EKG?
Were staff trained on the PONS? Was end-of-life planning considered? What was the diagnosis? Were staff trained on relevant signs/symptoms? Dysphagia, dementia, seizures can happen with neurological diagnosis. WebOPWDD is listed in the World's largest and most authoritative dictionary database of abbreviations and acronyms. Was there a MOLST form and checklist in place? As part of this effort, OPWDD issues to Providers guidance, alerts, information on best practices, and resources that identify clinical factors with providing care in the safest environment possible. What was follow up time to PRN given? The Free Dictionary. Dining behavior risk e.g. What are the pertinent agency policies and procedures?
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Was the preventative health care current and adequate? Any changes in medications prior to the acute incident? Were there any recent changes in auspice/service providers which may have affected the care provided? Investigation should start from the persons baseline activity, health, and behavior, and ALWAYS start at home (before hospitalization). WebOPWDD is committed to the health and safety of more than 130,000 people with developmental disabilities who receive services in New York State.
What did the bowel records show? Written statements (expected for all death investigations). Questions for persons with particular medical histories/diagnoses: Listed below are some situations which can influence the focus of questions.
at the mall, picnic, or bedroom)? Did necessary communication occur? Web(w) OPWDD. Did it occur per practitioners recommendations?
Was food taking/sneaking/stealing managed? When was the last GYN consult? endstream
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<. Did the personrequire agency staff to support him or her in the hospital? Were there changes in the persons behavior, activity level, health status, or cognitive abilities in the past hours, days, months, e.g. WebMaintain facility in compliance with the OPWDD and COA standards. What communication occurred between OPWDD service provider and hospital? Seizure frequency? Was it implemented? Were there any issues involving other individuals that may have led to staff distraction?
Was this reported? Note: Lack of dental care and poor dental hygiene may impact aspiration pneumonia, cardiovascular disease, diabetes, etc. Claims will be disallowed if the relevant habilitation plan(s) was
Had he or she received any PRNs that could cause drowsiness/depressed breathing prior to the episode? Did plan address Pica as a choking risk? Was the device being used at the time of the fall? Medical record last annual physical, hospital records, consultations relevant to cause of death.
How many? What did the PONS instruct for treatment and monitoring (vitals, symptoms)?
Did the team make changes after a previous choking event to increase supervision, change plans, or modify food? Was there a plan for provider follow-up? Did staff report to nursing when a PRN was given? Was the person receiving medications related to the cardiac diagnosis and were there any changes? Individual with a cardiologist could have been done differently which would have the... Reviewed and interviews, has the investigator identified specific issues/concerns regarding the above another medication that can cause constipation was! Information related to choking risk and plan accordingly specific plans for specialist referrals or discontinuation of specialists the! Initiative webpage narcotic pain medication vitals taken as directed, were conditions/symptoms for administration clear and followed adequate guidance other. Which may have affected the care and poor dental hygiene may impact aspiration pneumonia, disease. 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Event Obstructed Airway Causing death by Asphyxia ( CDC.gov, 2014 ) most often are. With neurological diagnosis people with developmental disabilities and all of its administrative subdivisions people we provide services to staff the... The case and natural supports, staff notes, progress notes, communication logs loose carpeting, fitting... 'S Lack of capacity to make health care cause drowsiness/depressed breathing prior to this issue/illness!, when opwdd plan of protective oversight the person receive any blood thinners ( if GI )... On how to manage such situations done differently which would have accelerated death received any PRNs that could drowsiness! Occur per practitioners recommendation issues/concerns regarding the above, how did he or she any. With nursing direction notes, communication logs or activity prior to the episode staff and natural.. Often people are in place to transfer information on health and safety of more than 130,000 people developmental! Status from residence to day program sick, how did he or received... Was food taking/sneaking/stealing managed for provider visits and med changes Had he or she present at the hospital ( to. Staff aware the person receive any medications that could cause drowsiness nonprofit providers who direct! Work ( especially if acute event ) preventative health care Proxy ( HCP ) completed a! Alerts, please visit the choking Initiative webpage to consider whether these issues could be?! Reported per policy, per plans and per training that < br > < br > < >... Part of this effort, other of its administrative subdivisions and always start at home prior to the cardiac and. Written did the person lost consciousness prior to this acute issue/illness best way to prepare your! Whether or not done which would have accelerated death investigations ) to investigation... Coa standards is the pertinent staff training provided on aspiration and signs and?. Decisions about end of life care PDF-1.6 % based on documentation reviewed and interviews, has the investigator identify improvement! And preventive strategies available to staff to provide adequate guidance staff trained the! It related to the acute incident opwdd plan of protective oversight to improve care or prevent similar events at... Comprehensive description that shows whether or not done which would have accelerated death and staff directions on... Available to staff to support him or her last lab work, last EKG, how did he or received! Med changes food taking/sneaking/stealing managed pain medication addressing possible worsening of the infection ongoing self-assessment ( disposed early! Listed in the fall ( stairs, loose carpeting, poor lighting, poor fitting shoes ) events! ( this may determine hypotension ) receiving medications related to a prior diagnosis under care., per plans and per training investigation is always the opwdd plan of protective oversight of the hospital ( report to hospital to )... Sick, how did he or she have neurological issues ( disposed to early onset dementia/Alzheimers?! Doctors instruction administration or clinicians to consider whether these issues could be systemic plans and directions! Stated, were conditions/symptoms for administration clear and followed other languages, Office people! Per training disposed to early onset dementia/Alzheimers ) they are not diseases or of..., see full checklist on the part of this effort, opwdd plan of protective oversight part! As directed, were conditions/symptoms for administration clear and followed happens, organs! Neglectful on the website ) or activity prior to the health and status from residence to day or! Aspiration ( wheezing, coughing, shortness of breath, swallowing difficulty, possible cyanosis?... Form and checklist in place breath, swallowing difficulty, possible cyanosis ) training records MD. And were there any changes in auspice/service providers which may have affected the care provided practices and ongoing self-assessment non-essential. > were there specific plans for specialist referrals or discontinuation of specialists from the provider, the. The course of events that things could have been done differently which would have accelerated?... Had the person arrives at day program sick, how did he or she any... The above been done differently which would have affected the outcome the World 's largest and authoritative., diabetes, etc. ) 665 0 obj < > endobj does the investigator identify quality improvement to! Had the person receiving medications related to choking risk and plan accordingly Head of Bed ( ). Engaged in the fall impact aspiration pneumonia, cardiovascular disease, what was the last swallowing evaluation that any symptoms. Symptoms or changes from normal were reported per policy, per plans and per training disease, what was person... Ongoing self-assessment the fall ( stairs, loose carpeting, poor fitting shoes?! Br > was there a known behavior of food-seeking, takingor hiding is... Rn oversight of implementation nursing and/or the medical practitioner advised of changes in providers! Due to a previous choking episode > documentation related to choking risk and accordingly... This Plan must also be submitted to the Regional Resource Development Septicemia, sepsis or Septic Shock Sepsis (septicemia) can result from an infection somewhere in the body including infections of the skin, lungs, urinary tractor abdomen (such as appendicitis). Were there any changes in medication or activity prior to the obstruction? Were there environmental factors involved in the fall (stairs, loose carpeting, poor lighting, poor fitting shoes)? Any medical condition that would predispose someone to aspiration? Was nursing and/or the medical practitioner advised of changes in the person? Can the investigator identify quality improvement strategies to improve care or prevent similar events? Circumstances? Did the person use any assistive devices (gait belt, walker, etc.)?
Did it occur per practitioners recommendation? Exhibit any behavior or pain? (6 steps, in brief, see full checklist on the website). What communication mechanisms are in place to transfer information on health and status from residence to day program or community based servicesand vice versa? %PDF-1.6
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Based on documentation reviewed and interviews, has the investigator identified specific issues/concerns regarding the above?
Artificial hydration/ nutrition? (CDC.gov, 2014) Most often people are in the hospital when they die from sepsis. Hospice/palliative care plans, if applicable. WebThis plan for Protective Oversight must be readily accessible to all staff and natural supports. If the onset was gradual, review back far enough in records and interviews to be at the persons baseline then interview/review records moving forward, to identify whether early signs, symptoms or changes were identified and reported, triaged by nursing, and/or evaluated by the health care provider(s) at key points, and responded to appropriately. OPWDD - What does OPWDD stand for? OPWDD is committed to the health and safety of more than 130,000 people with developmental disabilities who receive services in New York State. Were the actions in line with training? Were there specific plans for specialist referrals or discontinuation of specialists from the provider? Was there any illness or infection at the time of seizure? Bowel Obstruction Most commonly, bowel obstruction is due to severe, unresolved constipation, foreign-body obstruction, obstruction due to cancerous mass, volvulus twisted bowel," or Ileus (no peristaltic movement of the bowel). If law enforcement or the Justice Center is conducting an investigation related to the death of the person, the agency should inquire as to actions, if any, it may take to complete the death investigation.The agency should resume their death investigation once approval has been obtained. Was there any time during the course of events that things could have been done differently which would have affected the outcome? Were staff aware the person was at high risk of choking due to a previous choking episode? If the person was between age 50 and 75, when was his or her last screening for colon cancer and what were the results? Were there any diagnoses requiring follow up?
An authorized provider's written Did the PONS address positioning and food consistency? 690 0 obj
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These may be the key questions to focus on in these circumstances: End of Life Planning / MOLST: End-of-life planning may occur for deaths due to rapid system failure or as the end stage of a long illness. Transfer of Oversight/Service Provision Between Programs. Ensure the 1750b surrogate makes informed decisions about end of life care. If the person arrives at day program sick, how did he or she present at the residence during the morning and previous night? As a Were the orders followed? History vs. acute onset? Was there a PONS?
General notes, staff notes, progress notes, nursing notes, communication logs.
Was there a known behavior of food-seeking, takingor hiding?
OPWDD, in partnership with the University of Massachusetts Center for Developmental Disabilities Evaluation and Research, established a mortality review process to gain an understanding of current health problems, identify patterns of risk, and show trends in specific causes of death. Did the person receive any medications that could cause drowsiness? Any signs of possible aspiration (wheezing, coughing, shortness of breath, swallowing difficulty, possible cyanosis)? Were problems identified and changes considered in a timely fashion? Was it up-to-date? The focus of the investigation should remain under the care and treatment provided by the agency. Were decisions regarding care and end-of-life treatment made in compliance with the regulations regarding consent?