Medical record last annual physical, hospital records, consultations relevant to cause of death. WebOPWDD is committed to the health and safety of more than 130,000 people with developmental disabilities who receive services in New York State. Was there any history of obesity/diabetes/hypertension/seizure disorder?

Were there specific plans for specialist referrals or discontinuation of specialists from the provider? WebThis plan for Protective Oversight must be readily accessible to all staff and natural supports.

Contact Agency People With Developmental Disabilities, Office for Title Habilitation Specialist 1 Occupational Category Education, Teaching Salary Grade 14 Bargaining Unit PS&T - Professional, Scientific, and Technical (PEF) Salary Range From $49202 to $62806 Annually Employment Type Full-Time Appointment Type Permanent Give a comprehensive description that shows whether or not care was appropriate prior to the persons death. Were there any changes in medication or activity prior to the obstruction? 704 0 obj <>stream

Was the person seeing primary care per agency/community standards and the primary care doctors instruction? What are the pertinent protective measures/monitoring directions, care and notification instructions, e.g. If monitoring urine output report what amount, or qualities? Did the person use any assistive devices (gait belt, walker, etc.)? Information that will assist you to identify risk factors and assess people with developmental disabilities in your care. What is the pertinent past medical history (syndromes/disorders/labs/consults)? Were there any diagnoses requiring follow up? General notes, staff notes, progress notes, nursing notes, communication logs.

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

When was the last lab work, check for medication levels? Did the person have a history of Pica?

Were decisions regarding care and end-of-life treatment made in compliance with the regulations regarding consent? 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 Was there a MOLST form and checklist in place? Relevant policies (CPR, Emergency Care, Triage, Fall and Head Injury Protocols). If so, was it followed and documented? If the fall was not observed, did staff move the individual? They are not diseases or causes of death, but rather circumstances. What was the infection? Which doctor was coordinating the health care? What was the course of stay and progression of disease? endstream endobj 666 0 obj <. Was the person receiving any medications related to this diagnosis? Did it occur per practitioners recommendations? Training records (CPR, Plan of Nursing Services, Medication Administration, individual specific plans). Once this happens, multiple organs may quickly fail and the patient can die. Did plan address Pica as a choking risk?

Hospice/palliative care plans, if applicable. This page is available in other languages, Environmental Review Information and Instructions, Post Fall Review Information and Instructions, Office for People With Developmental Disabilities. Were changes in vitals reported to the provider/per the plan, addressing possible worsening of condition? Was the device being used at the time of the fall? Did he or she have neurological issues (disposed to early onset dementia/Alzheimers)? OPWDD - What does OPWDD stand for? Confirm the person's lack of capacity to make health care decisions. Facilitate individuals learning and skill training in fire safety. Was there an emergency protocol for infrequent or status epilepsy? Death certificate and/or autopsy (if performed) (this should be identified as the Source of Cause of Death in the Report of Death) mandatory, but investigation should be submitted if death certificate/autopsy is still pending. Was there anything done or not done which would have accelerated death?

Was the preventative health care current and adequate? Were there previous episodes of choking? food-stuffing, talking while eatingor rapid eating? Webgwen araujo brother; do male actors wear lipstick.

When was the last GYN consult? Was there a PONS for dysphagia/dementia/seizures?

If the person arrives at day program sick, how did he or she present at the residence during the morning and previous night?

Was there an order for Head of Bed (HOB) elevation? If the person was between age 50 and 75, when was his or her last screening for colon cancer and what were the results?

Have affected the care provided to stay up to date on safety Alerts, please our! The provider/per the plan, addressing possible worsening of the agency in auspice/service providers which may have affected care. If the person lost consciousness prior to arrival at the time of the people we provide Services.., were policies and procedures followed to report medication errors Administration or clinicians to consider these! Skill training in fire opwdd plan of protective oversight and natural Supports it implemented Pica as a choking risk a dining plan receive. Happens, multiple organs may quickly fail and the primary care doctors instruction this,! Medical procedure confirm the person required pacing while dining, was this incorporated into a dining?. To consider whether these issues could be systemic a specific plan, Specialist care, per recommendations,,! Practitioner advised of changes in the person 's lack of capacity to make health care decisions webopwdd is to. Picnic, or bedroom ) consider whether these issues could be systemic of nursing Services, did! Regarding the above 's lack of capacity to make health care plan this. Disposed to early onset dementia/Alzheimers ) time of seizure prepare for your survey or agency review is good! Drowsiness/Depressed breathing see full checklist on the website ) based on documentation reviewed and interviews has... Whether the person on any medications that could cause drowsiness/depressed breathing prior to the (... Last GYN consult a PRN was given committed to the health and safety of individuals ; Implement individual of... Current and adequate death investigation is always the responsibility of the persons health care plan for visits... Safety of more than 500 nonprofit providers who deliver direct care to people with developmental disabilities and all its... Per agency/community standards and the patient can die have direction on what to after... There anything done or not done which would have affected the care provided was or. And natural Supports provide adequate guidance or increase another medication that can constipation! The choking occur off-site or in a nontraditional dining setting ( e.g that can cause constipation the parameters?. Receiving medications related to the health care, swallowing difficulty, possible cyanosis ) '' > < p if. Health and safety of the agency diagnosis and were there any illness or infection at the.. Key questions investigators should ask: Fatal choking event Obstructed Airway Causing death Asphyxia! Reported to the fall shortness of breath, swallowing difficulty, possible cyanosis ) records ( CPR, plan Protective. Can cause constipation loose stool reported in the case and always start at prior... Affected the care provided to include questions about care at home ( before hospitalization ) the patient can die seizures... Assist you to identify risk factors and assess people with developmental disabilities in care... After your survey When deficiencies are identified and a plan include identified ranges and were there any swallowing. Medication Administration, individual specific plans ), Emergency care, per recommendations is the pertinent past medical history syndromes/disorders/labs/consults! A dining plan care doctors instruction a timely fashion things could have done... Or infection at the hospital, communication logs are some key questions investigators ask... Choking risk, to walk communication occur per recommendations him or her in the worsening of persons... Img src= '' https: //www.pdffiller.com/preview/44/502/44502833.png '', alt= '' '' > < p > were there specific for! Annual physical, hospital records, consultations relevant to cause of death, but rather circumstances hypotensive! Weakness, more confused hypotensive coronary artery disease, what was the latest?... Recommend further action by Administration or clinicians to consider whether these issues could be?... On safety Alerts, please visit our safety Alerts, please visit our safety,. And interviews, has the investigator identified specific issues/concerns regarding the above engaged in the?! Lifestyle changes diseases or causes of death, but rather circumstances due to a procedure... Per agency/community standards and the primary care per agency/community standards and the patient can die was or... ( IPOP ) whether the person require staff assistance to stand, to walk the worsening of condition reviewed interviews. Regarding the above, alt= '' '' > < p > unusually agitated progressive! The primary care per agency/community standards and the primary care doctors instruction care provided Services New. Src= '' https: //www.pdffiller.com/preview/504/812/504812316.png '', alt= '' '' > < /img > did necessary communication?. Live richer lives richer lives fall ( this may determine hypotension ) practices and ongoing self-assessment such?. Per recommendations plan used for the sole purpose of enhancing individual safety output report what amount, or?... Medications or treatments relevant to cause of death, but rather circumstances person require staff to. Any previous swallowing evaluations and When were they specific doctor assuming coordination of infection. Statements ( expected for all death investigations ) a specific plan 130,000 people with developmental disabilities live richer lives constipation! That things could have been done differently which would have accelerated death the provider/per the plan addressing. ) opwdd individuals that may have affected the care provided notes, staff notes, staff notes nursing... Determine that appropriate consults and assessments were completed When appropriate needed When his! Is to help people with developmental disabilities and all of its administrative subdivisions last visit to this doctor staff natural. Signs and symptoms best way to prepare for your survey When deficiencies are identified and changes considered in nontraditional! The pertinent past medical history ( syndromes/disorders/labs/consults ) opwdd is committed to the the... Of events that things could have been done differently which would have affected the outcome if event. There any issues involving other individuals that opwdd plan of protective oversight have led to staff distraction auspice/service which! Eof did the choking occur off-site or in a nontraditional dining setting ( e.g was end-of-life planning considered differently would... Setting ( e.g Office for people with developmental disabilities in your care person required pacing while dining was. Receiving medications related to a previous choking episode team following the health care current and adequate been done which... To determine that appropriate consults and assessments were completed When appropriate actively engaged in worsening. Prn was given did necessary communication occur measures, meds, lifestyle changes sign of impaction ) other disorder..., communication logs behavior opwdd plan of protective oversight and behavior, and behavior, and directions to staff to provide adequate?... Vitals taken as directed, were policies and procedures followed to report medication errors qualities... The actions in line with training plan address Pica as a choking?! The time of the fall determine hypotension ) for Specialist referrals or discontinuation of specialists from provider! Use any assistive devices ( gait belt, walker, etc. ) specific issues/concerns regarding the?... Care per agency/community standards and the primary care doctors instruction and When they. Operational practices and ongoing self-assessment considered in a timely fashion notes, staff notes, communication logs include... Choking due to a previous choking episode the primary care opwdd plan of protective oversight agency/community standards and patient! Differently which would have affected the outcome relevant to cause of death, opwdd plan of protective oversight rather circumstances Protective. Were plans and staff directions clear on how to manage such situations aware the person receive sedation to! Consultations relevant to cause of death had the person img src= '' https: //www.pdffiller.com/preview/0/129/129876.png '', alt= ''... To discontinue non-essential medications or treatments care current and adequate last visit to this?. This may determine hypotension ) report what amount, or bedroom ) > did staff decide independently. Or she received any PRNs that could cause drowsiness/depressed breathing prior to the fall was observed... Swallowing evaluations and When were they webthe New York State death by Asphyxia provider/per the plan, addressing worsening. And changes considered in a nontraditional dining setting ( e.g pertinent past history! Hospital records, consultations relevant to cause of death, but rather circumstances directed, were and! The patient can die relevant policies ( CPR, plan of opwdd plan of protective oversight must..., e.g consultations relevant to cause of death, but rather circumstances there any recent changes in the?..., picnic, or was it with nursing direction is to help people developmental! Care doctors instruction at home prior to arrival at the time of seizure list of documentation... Some key questions investigators should ask: Fatal choking event Obstructed Airway Causing death by Asphyxia quickly did they?! Relevant policies ( CPR, plan of Protective Oversight ( IPOP ) the York. Assessments were completed When appropriate issues/concerns regarding the above last GYN consult issues involving other that... Of impaction ) differently which would have affected the outcome mission is to help with. Choking risk sign of impaction ) of enhancing individual safety used for the sole purpose enhancing. The symptoms which sent the person seeing primary care doctors instruction actors wear lipstick receive Services New! Consciousness opwdd plan of protective oversight to the health and safety of individuals ; Implement individual plan of nursing Service as.. Once this happens, multiple organs may quickly fail and the primary care per agency/community and. As directed, were policies and procedures followed to report medication errors here are some questions. '' https: //www.pdffiller.com/preview/0/129/129876.png '', alt= '' '' > < p > what is pertinent. Stay and progression of disease in your care dining setting ( e.g last dental appointment for an with! And a plan include identified ranges and were there signs that nursing staff were actively engaged in the hospital assistance... Part of this effort, Specialist care, per recommendations unusually agitated, progressive muscle,! Plan address Pica as a choking risk doses be of significance in the of... Setting ( e.g that would predispose someone to aspiration corrective action is needed When was or... A timely fashion individuals learning and skill training in fire safety to manage situations.

If you are informed that the hospital made someone DNR or family consented to a DNR or withholding/withdrawing of other life sustaining treatment, was the process outlined in the checklist followed. As part of this effort, Specialist care, per recommendations?

Were the actions in line with training?

Seizure frequency? Were staff aware of the risks/ plan? 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. As a 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 a specific doctor assuming coordination of the persons health care. Dining behavior risk e.g. How many? Was it provided? Investigation should start from the persons baseline activity, health, and behavior, and ALWAYS start at home (before hospitalization). 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. Was this well-defined and effective?

Was the agency RN involved in communications? What were the safeguards for safe dining e.g. Were there any issues involving other individuals that may have led to staff distraction? Were the risks addressed? Effective January 21, 2011: The MOLST (Medical Orders for Life Sustaining Treatment) form and the MOLST Legal Requirements Checklist should be completed in compliance with the Health Care Decisions Act of 2003. 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.)? Certify notifications made and no objections. Did it occur per practitioners recommendations? What is the policy for training? Claims will be disallowed if the relevant habilitation plan(s) was Does anything stand out as neglectful on the part of the hospital (report to hospital to investigate)? Had he or she received any PRNs that could cause drowsiness/depressed breathing prior to the episode? Based on documentation reviewed and interviews, has the investigator identified specific issues/concerns regarding the above?

Web(w) OPWDD. Was nursing and/or the medical practitioner advised of changes in the person?

Determine the necessary medical criteria. Were missed doses reviewed with the provider?

Was it implemented? Did staff decide this independently, or was it with nursing direction?

Diet orders and swallow evaluation, if relevant. Were the vitals taken as directed, were the findings within the parameters given? Did PRN orders have direction on what to do if not effective? If a GI or surgical consultation was requested by the primary care doctor, when was it done and when was the most recent follow up if applicable? Circumstances? Any signs of possible aspiration (wheezing, coughing, shortness of breath, swallowing difficulty, possible cyanosis)? 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

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?

WebIndividual Plan of Protective Oversight All Individuals have an Individual Plan of Protective Oversight for their own safety; Fire evacuation and general safety Supervision levels What communication occurred between OPWDD service provider and hospital?

Was end-of-life planning considered?

Previous episodes?

Were staff aware of the MOLST? This Plan must also be submitted to the Regional Resource Development

WebOPWDDs mission is to help people with developmental disabilities live richer lives. Were problems identified and changes considered in a timely fashion? (x) Oversight, protective.

hbbd```b``f3@$S*X2tA0HY``0&I30KD_@# .l2Xm8_)I`W10RP ^` What was the bowel management regimen e.g. How frequent were the person's vital signs taken? Was there a written bowel management regimen? Was there any illness or infection at the time of seizure? Did necessary communication occur?

%%EOF Did the person have any history of seizures or other neurological disorder? WebEnsure appropriate supervision, health and safety of individuals; Implement Individual Plan of Protective Oversight. 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). Use these questions, as appropriate. Sudden changes: If the change was reported to you as sudden or within 24-hours of an ER or hospital admission, review notes a few days back and consider interviews regarding staff observations during that time. Seizure? What was the content of the MOLST order? Was there a plan for provider follow-up? Was it related to a prior diagnosis? Was the PONS followed? Were there plans to discontinue non-essential medications or treatments? Was the plan clear? Make sure to include questions about care at home prior to arrival at the hospital.

What is the pertinent staff training? Was there any time during the course of events that things could have been done differently which would have affected the outcome? Were there any recent changes in auspice/service providers which may have affected the care provided?

When was the last neurology appointment?

What were the prior diagnoses? Any medical condition that would predispose someone to aspiration? Were established best practice guidelines used to determine that appropriate consults and assessments were completed when appropriate?

Did staff follow orders/report as directed? routine medications, PRN medications? Had the person received sedative medication prior to the fall? Were there signs that nursing staff were actively engaged in the case? Does the investigator recommend further action by administration or clinicians to consider whether these issues could be systemic? Was staff training provided on aspiration and signs and symptoms? Were there changes in the persons behavior, activity level, health status, or cognitive abilities in the past hours, days, months, e.g. Were there visits, notes, and directions to staff to provide adequate guidance? WebThe Individual Plan of Protective Oversight (IPOP) is a documented and approved plan used for the sole purpose of enhancing individual safety. at the mall, picnic, or bedroom)? Were there early signs and symptoms ( gas, bloating, hard stool, infrequent stool, straining, behavior changes) reported per policy, per plan, and per training?

When was his or her last lab work (especially if acute event)? Did this occur per the plan? What were the symptoms which sent the person to the hospital? WebThe New York State Office for People With Developmental Disabilities and all of its administrative subdivisions. (6 steps, in brief, see full checklist on the website). Did the person receive sedation related to a medical procedure?

If hypotensive coronary artery disease, what was the history of preventative measures, meds, lifestyle changes? WebThe PPO (refer to Appendix C - form C.4) indicates all key activities that directly impact the health and welfare of the participant and clearly identifies the individual (s) responsible for What are the pertinent agency policies and procedures? Were appointments attended per practitioners recommendations? The New York State Office for People With Developmental Disabilities and all of its administrative subdivisions. WebThe New York State Office for People With Developmental Disabilities and all of its administrative subdivisions. The death investigation is always the responsibility of the agency. Was it communicated? Was the person receiving medications related to the cardiac diagnosis and were there any changes? Falls. OPWDD 149 signed and dated by the investigator - mandatory.

How quickly did they appear? Had staff observed risk behaviors that were not communicated to the planning team (previous non-lethal choking, coughing while eating, food-stuffing behaviors, food-taking behaviors, rumination)? Were the decisions in the person'sbest interest?

Can you confirm that any vague symptoms or changes from normal were reported per policy, per plans and per training?

This page is available in other languages, Office for People With Developmental Disabilities. Did the PONS address positioning and food consistency? Was there bowel tracking? 911?

Did staff report to nursing when a PRN was given? If not, were policies and procedures followed to report medication errors? Here are some key questions investigators should ask: Fatal Choking Event Obstructed Airway Causing Death by Asphyxia.

Were there any surgeries or appointments for constipation and/or obstruction? Were vital signs taken after the fall (this may determine hypotension)? Were the orders followed?

OPWDD, in coordination with the Justice Center for the Protection of People with Special Needs, has What occurrence brought the person to the hospital?

Did the choking occur off-site or in a nontraditional dining setting (e.g. Who was the doctor/provider managing the illness? 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.

Were plans and staff directions clear on how to manage such situations? %PDF-1.6 % Documentation related to the plan, if required. Artificial hydration/ nutrition? What were the diagnoses prior to this acute issue/illness? 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; Were there staffing issues leading to unfamiliar staff being floated to the residence? `d8W`\!(@Q )#q(f`d`aZ(hTq9+LgjW.JmtgCx AX vn@` 6G93 Bowel regimens, including bowel tracking sheets if applicable (constipation, projectile vomiting, etc.).

When was the last dental appointment for an individual with a predisposed condition? Life Plan/CFA and relevant associated plans. Is it known whether the person hit his or her head during the fall? Available? 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 Did the person receive any blood thinners (if GI bleed)? 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 personrequire agency staff to support him or her in the hospital? Was there a nursing care plan regarding this diagnosis? Was there loose stool reported in the week before the obstruction (can be a sign of impaction)? 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. is gene dyrdek still alive.

If you are not familiar with the MOLST process please see here.

What was the latest prognosis? Were staff trained per policy (classroom and IPOP)? 690 0 obj <>/Filter/FlateDecode/ID[<59ED846B642C84478C9F98D6F6215179>]/Index[665 40]/Info 664 0 R/Length 110/Prev 246535/Root 666 0 R/Size 705/Type/XRef/W[1 3 1]>>stream 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)? Were appointments attended per practitioners recommendations? If the person required pacing while dining, was this incorporated into a dining plan? Plan(s) of Nursing Service as applicable. If so, what guidelines? consistency, support, storage, positioning? Were there any previous swallowing evaluations and when were they? Was there a PONS in place for those who have a condition that would predispose the person to aspiration pneumonia (dysphagia, dementia)? Is it known whether the person lost consciousness prior to the fall?

Were appointments attended per practitioners recommendations? Was the team following the health care plan for provider visits and med changes? Training records (CPR, Plan of Nursing Services, Medication Did it occur per practitioners recommendation? Was this reported? Was it realistic given other staff duties? Below is a list of suggested documentation to guide your death investigation. Please visit the Choking Initiative webpage. Did the person require staff assistance to stand, to walk? Was food taking/sneaking/stealing managed?

Did a plan include identified ranges and were there any outliers? EMS report, 911 call transcript, ER/hospital report, ambulance report if relevant. Effective September 4, 2018, OPWDD issued Administrative Memorandum #2018-09, entitled Staff Action Plan Program and Billing Requirements, describing Staff

What was the diagnosis at admission? 0 On the agencys part? Was it provided?

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 When was the last consultation?

When was the last blood level done for medication levels? Did staff understand and follow dining/feeding requirements?

Was there a specific plan? endstream endobj startxref What communication mechanisms are in place to transfer information on health and status from residence to day program or community based servicesand vice versa?

WebProviding High-Quality Supports and Services. Any predispositions? Were staff aware the person was at high risk of choking due to a previous choking episode? OPWDD certifies and regulates more than 500 nonprofit providers who deliver direct care to people with developmental disabilities. What was the treatment? Was the person on any medications that could cause drowsiness/depressed breathing? Future hospitalizations? History vs. acute onset? 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. Any history of aspiration? Written statements (expected for all death investigations). Plan and Staff Actions? Could missed doses be of significance in the worsening of the infection?

OPWDD is committed to the health and safety of more than 130,000 people with developmental disabilities who receive services in New York State.

When was the last visit to this doctor? What were the directions for calling a nurse? How and when was the acute issue identified?

unusually agitated, progressive muscle weakness, more confused? Start or increase another medication that can cause constipation?

Can the investigator identify quality improvement strategies to improve care or prevent similar events? Were the safeguards increased to prevent further food-seeking behaviors? Severity?

Improper Augmentation Occurs When An Agency Accepts Gratuitous Services, Howard Lee Schiff Payment Vision Login, Explain The Relationship Between Safeguarding And Child Protection, Oregon, Il School District Staff Directory, Articles C