JAH.0114.0001.

0160

Manual CI&MGT
Document CIMGT.Pro.009
INCIDENT REPORTING Version 21
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To ensure incidents and events are recorded, collated, trends and anomalies are
PURPOSE identified, monitored, acted upon and resolved.
SCOPE All events, incidents, accidents and near misses throughout the home.
Accreditation Standards – Expected Outcomes:
1.1, 2.1, 3.1 & 4.1 - Continuous Improvement;
1.2 – Regulatory Compliance;
2.7 – Medication Management;
4.5 – Occupational Health & Safety;
4.7 – Infection Control
REFERENCES Aged Care Act 1997
o Section 62-1
o Section 63-1AA
o Section 96 - 8
Accountability Principles 2014 – Section 62-1
Compulsory Reporting Guidelines For Aged Care Providers: Identifying,
reporting and responding to allegations of assault in residential aged care.
Privacy Act 1988
Group Executive- Care and Commercial, State General Manager, Quality
RESPONSIBILITIES Manager, Home Manager, Deputy Home Manager, Registered Nurses, Clinical
Care Coordinators and all staff.
Incident Report CIMGT.Fm.030
Monthly Incident-Accident Report
CI&MGT.IncRep.Fm.008
Incident Report Register/ Compulsory Reporting Excel spreadsheet
FORMS
Register
Reportable Assault Report (Department Form) External document
Unexplained Absence Report (Dept form) External document
Feedback Form

NO.
1.1 Definitions
Whenever an incident, accident or near miss occurs, which involves the health, safety or well
being of any person living, working or visiting the home, an Incident Report is completed.

Resident behaviours or actions which place the health, safety or well being of other residents or
staff at risk are included in the incident reporting system. However, unusual behaviours by
residents which do not place the health, safety or well being of other residents at risk are not
included in the Incident Reporting System but must be reported to the person in charge of the
shift and recorded in the residents’ progress notes.

It is important that facilities consistently gather the same information to ensure that the
Benchmarks remain valid and statistically correct therefore the following definitions are used as
guidelines.
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NO.

Fall:
 A resident fall is defined as a resident on the ground secondary to an unplanned occurrence.
It includes witnessed, un-witnessed, deliberate, accidental episodes and episodes that do not
result in injury to the resident.
Injury:
 Injury is defined as a disruption of structure or function of some part of the body as a result of
an unplanned event (e.g., skin tears, wounds, pressure areas, fractures with or without
treatment, sprains, cuts, bruises, aggravation of pre-existing complaints such as back pain,
etc.).
Skin Tears:
 Incident Report a skin tear (whether self-inflicted or accidental) if the skin tear is greater than
2cm. in size.
Record the type as per the following categories:
 Category I – Skin tears without tissue loss. In a linear type Category 1 skin tear; the
epidermis and dermis have been pulled apart, as if an incision had been made. In a flap
type Category I skin tear; the epidermal flap completely covers the dermis to within 1 mm
of the wound margin.
 Category II – Skin tears with partial tissue loss. With a scant tissue loss type. Category II
skin tear, 25% or less of the epidermal flap is lost. When more than 25% of the epidermal
flap is lost, the Category II skin tear is referred to as a moderate to large tissue loss type
skin tear.
 Category III – Skin tears with complete tissue loss. The epidermal flap is absent in this
type of skin tear.
Bruises:
 Incident Report a single bruise (whether self-inflicted or accidental) if it is greater than 2cm in
size or multiple bruises of any size.
Pressure Areas:
 All pressure areas observed by staff are to be reported on an incident report.
 Record the type as per the following categories:
 Inherited or Sustained in the home AND;
 Stage 1 - Intact skin with observable changes including areas of persistent redness.
 Stage 2 - Partial thickness skin loss involving epidermis and/or dermis.
 Stage 3 - Full thickness involving damage or necrosis of subcutaneous tissue that may
extend down to, but not through, underlying fascia.
 Stage 4 - Full thickness skin loss with extensive tissue destruction to muscle, bone, or
supporting structures i.e. tendon, joint capsule. May have undermining or sinus formation.
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NO.

Aggression:
 Aggression is defined as any incident in which a resident, employee or visitor is abused,
threatened or assaulted by fellow employees or a resident or a member of the public within
the home.
Security Incidents:
 Can include but are not limited to theft, bomb threat, arson, assault or entry by an un-
authorised person.
Medication Incidents:
 A medication incident is any preventable event that may cause or lead to in-appropriate
medication use or resident harm while the medication is in the control of the health care
professional, patient, or consumer.
 Such events may be related to professional practice, health care products, procedures and
systems, including prescribing; order communication; product labelling, packaging and
nomenclature; compounding; dispensing; distribution; administration; education; monitoring
and use.
 The definition includes any error in date, dose, time, route, form and reporting of
medication.
Critical Incidents:
Critical Incidents are defined as major incidents that place residents, visitors or staff at significant
risk related to their health, safety or well being. Critical incidents also include incidents that place
the operation of the home or the organisation at significant risk and/or an insurance claim. These
can include, but are not limited to:

 A resident transferred to hospital following a fall

 A resident transferred to hospital with a condition that may result in serious complications
and places the organisation at risk
 A resident has an unexplained absence and is found outside the site boundaries of the
home
 A resident is injured by another party (includes unintentional)
 Medication error resulting in injury, hospitalisation or death
 Death in hospital following surgery or medical procedure
 A fracture following a fall, diagnosed at the home.
 A Stage 3 or 4 pressure area
 A fire, flood, storm damage
 Property damage (eg. Pipe bursts)
 Machinery breakdown (sudden or unexpected) not due to age
 Loss of stock (eg. Cool room, freezer breakdown, spoilage occurs, stock discarded)
 Major theft
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NO.
 Missing S8 medications
 Gastro or influenza outbreak
 Request from family or other party for a resident’s file
 Legal letter stating malpractice and seeking damages
 Member of public, visitor, contractor sustains injury
 A reportable death or request for resident files from the Coroner
 Motor Vehicle Accident
 Etc.
The Registered Nurse (or person in charge of the shift) must contact the Home Manager (or
delegate) as soon as a Critical Incident or Compulsory incident occurs. The Critical Incident
procedure is instituted following authorisation of the State General Manager or delegate in
consultation with the Home Manager. See Section 8.

Compulsory Reports
See Section 7.

INCIDENT FORM PROCEDURE

2.1 Incidents, events and accidents are recorded on the Incident Report [CIMGT.Fm.030]

This should be completed as soon as possible after the occurrence of the incident. Part A should
be completed by the end of the shift.
2.2 The person reporting the incident (this could be any member of staff) completes Part A of the
Incident Report in consultation with the Registered Nurse or person in charge of the unit that shift.
Part B should be completed by the Registered Nurse or person in charge of the unit to record
immediate actions taken. Additional information may be added to Part B as the investigation,
follow up and treatment progress and the incident is closed.

2.3 The person(s) completing Part A of the form is responsible for ensuring the Incident Report is
completed with factual and objective data. Incidents involving a resident must have a
commensurate entry in the resident’s Progress Notes.

2.4 Once Part A of the Incident Report has been completed, it and any associated forms are placed in
the tray in the Nurses Station until the Incident Report is reviewed and collected by the Home
Manager or delegate.

2.5 When Part B of the Incident Report has been completed and the incident logged in administration
by the Home Manager or delegate, the original of the Incident Report and associated forms are
returned to the unit; the Registered Nurse or delegate shall place these in the residents' progress
notes. (The incident report and forms are placed with the progress note entry to which the incident
report relates.) This should be completed as soon as practicable after the incident has occurred.

A photocopy of the original of the completed Incident Report will be logged and then collated and
archived in the Incident Report folder in Administration by the Home Manager delegate
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NO.
RESIDENT INCIDENT PROCEDURE
3.1 Any incident involving a resident must be reported to the person in charge of the shift when the
incident occurs or as soon as practicable after the incident.

The Resident’s NOK or specified first contact must be notified as soon as practicable of the
incident and what actions have been taken.
3.2 Falls Management
 Falls can result from a slip or a trip due to an environmental hazard or the resident’s health
status.
 Staff should always suspect a fractured hip when a resident falls, particularly female residents.
 The signs and symptoms of a fractured hip are:
o pain , particularly on movement
o external rotation of the leg when the resident lies flat
o the leg may appear shorter than the other
o limited or abnormal range of movements
o oedema (swelling) and tissue discolouration
o a protruding bone through the skin with an open fracture
First aid
 Lie the resident as flat as possible with a pillow under her/his head.
 If in severe pain, place in a position that is the most comfortable.
 Assess limb circulation, limb pulses, colour, warmth, sensation and swelling.
 Pad the knees and heels with a towel.
 If the resident is on the floor do not attempt to lift them without assistance (if a fractured hip is
suspected, this should be done with at least 3 staff, keeping the resident’s body aligned).
 Do not give the resident anything to eat or drink
 Ring the resident’s medical practitioner and an Ambulance
 Notify the resident’s family
 Reassess circulation and vital signs.
 Transfer to hospital if required.
 Look for other injury for example, any fall can result in a spinal injury in the elderly, a skin tear
or bruising.

3.3 FALLS:
At the time of the incident, all residents who fall should have a set full set of observations
(temperature, pulse, respirations, blood pressure and head injury observations) taken and
recorded on the incident report and in the progress notes.

Neurological Observations:
If a fall is witnessed and the resident was observed to hit their head, staff shall complete a set of
head injury observations half (½) hourly for at least 4 hours or as ordered by the Medical
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NO.
Practitioner.

If the fall was not witnessed staff shall complete a set of head injury observations half (1/2) hourly
for at least 4 hours or as ordered by the Medical Practitioner.

If the fall was not witnessed and the resident clearly states that they did not hit their head, an
initial set of head injury observations are taken as per above, but head injury observations for 4
hours are not required. A notation must be made on the Incident Report and in the Progress Notes
stating that the resident reported not hitting their head.

These observations should be recorded on a Neurological Observation Chart (HPCL.Fm.064).

If the observations are stable after the initial 4 hours post fall, the Registered Nurse is to make an
informed clinical decision whether to continue the observations at less frequent intervals or to
cease the observations.

Neurological observations are only ceased after appropriate review by the Registered Nurse on
duty (or at the direction of the Medical Practitioner).

The Neurological Observation Chart is stapled to the original Incident Report and after review of
the incident by the Home Manager or delegate these are placed in the resident’s Progress Notes.

3.4 The Registered Nurse or Person in Charge of the unit that shift must notify the residents’ Medical
Practitioner at the time of the incident if the resident:

 Had a fall (injury or no injury)

 Is injured in any way
 Currently on anti-coagulant therapy or anti-platelet agents (not aspirin)
 Or the well-being of the resident has been compromised in any way
Please Note: A resident on anti-coagulant therapy or anti- platelet agents is at high risk for
bleeding. If the resident has hit their head or it is suspected they have hit their head or the medical
practitioner is unable to be consulted, the Registered Nurse must send the resident to the
Emergency Department for medical review and and alert them to the residents medications.

Where an injury has not occurred and a medical practitioner is not required to attend, the person
in charge is to record this on the Incident Report and in the progress notes.

The person in charge of the unit that shift must notify the residents’ family or preferred contact
person as stipulated in the residents file as per the notification request expressed by the family or
nominated person

3.4 All details regarding the incident; follow up action taken including the name and time of contact of
the person/s notified must also be recorded in the residents' progress notes.

If no relative or nominated person is able to be contacted- record the date & time & person who
you were attempting to contact in the progress notes.
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STAFF INCIDENT PROCEDURE

4.1 Check the staff member is alright and institute appropriate first-aid as required. Call 000 if an
emergency

4.2 The Injury Hotline is contacted on 1800 244 730 by the Home Manager, CCC or RN with the
employee present at the time of the incident to log the incident and give appropriate advice to the
staff member regarding treatment; actions to take and for follow-up.

4.3 An incident report will be completed by the Injury Hotline at the time of reporting. This replaces
completion of CIMGT.Fm.030 Incident Report

4.4 The Home Manager will receive an email notification and link to complete the investigation online

4.5 The person in charge will report all incidents including those requiring medical treatment and/or
time loss to the Home Manager (or delegate) as soon as practicable in person or via telephone.

4.6 A copy of the Incident details will be provided to the staff member.

4.7 The Home Manager (or delegate) ensures a print out of the incident report form is filed in the
employee’s personnel file.

4.8 All incidents involving staff time loss and medical treatment must have the Staff Incident
Investigation Report tabled at the Staff/CQI and Workplace Health and Safety/ Infection Control
Combined Meeting for discussion. De-identify before discussing.

4.9 The Home Manager (or Delegate) can use the online register as a master file of all staff incident
reports in accordance with the relevant State Work Cover requirements.

SECURITY INCIDENT PROCEDURE

5.1 An Incident Report is completed immediately upon an incident involving a breach of security (e.g.:
theft, unlawful entry, etc.) being reported.

5.2 The Home Manager (or delegate) is notified immediately by telephone upon a breach of security.
The Home Manager (or delegate) shall assess the report and if applicable, contact the relevant
authorities to report the incident for investigation.

5.3 The Incident Report is forwarded to Administration for appropriate, timely action following the
incident.

5.4 An investigation is to be completed by the Home Manager and recorded on the Incident Report. A
copy is to be sent to the State General Manager.
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MEDICATION INCIDENT PROCEDURE

Administration Involving a Resident

6.1 For incorrect administration involving a resident; notify the RN in charge of the home at that
time, they will notify the Pharmacy (or Poisons Information Line) and Medical Practitioner and
institute any instructions given. The RN in charge will notify the Home Manager (or delegate) and
inform family or designated person (as per documented preferred contact details).

6.2 For incorrect administration involving a resident; FM will inform the State General Manager
and the Human Resources representative immediately. Send through the Incident Report to them
once completed.

6.3 For all medication incidents; Complete Part A of an Incident Report and record the incident,
observations and actions taken including who was notified and when in the residents progress
notes.

6.4 The Incident Report and a photocopy of the completed form is forwarded to the Home Manager
(or delegate) for processing.

6.5 Detail follow up/ education provided to any or all staff without identifying staff names. Records of
disciplinary procedures following a Medication Incident should only be kept in the home’s HR files.

Pharmacy Error

6.6 Withdraw the medication from use and notify the Pharmacy and fax a copy of the Incident Report
to the Pharmacy as soon as practicable.

6.7 Record the incident on the Monthly Register of Incidents in the relevant area.

6.8 Complete the Incident Report and submit to Home Manager (or delegate) for follow-up.
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COMPULSORY REPORTING
PURPOSE
In order for the organisation to comply with the Compulsory Reporting requirements of the
7.1
Aged Care Act (Section 62-1 & Section 63) and the Accountability Principles 2014, reports of
suspected or alleged reportable assaults or when residents have an unexplained absence and/or
are reported missing to the police, this must be reported immediately if either an incident is
suspected or occurs to enable the Approved Provider to comply with the 24 hour timeframe
required under the Act.

Thorough documentation ensures that there are accurate records that can be reviewed and acted
upon in order to minimise or prevent similar incidents recurring.

7.2 Proper investigation and documentation of a critical incident investigation on the Incident Report is
to document details of the event, identify any causes or triggers to the incident and to ensure the
risk of future incidents is prevented or minimised. The Incident Report for a critical incident and all
documentation regarding critical incidents should be completed with due consideration of the legal
and regulatory requirements and implications.

Compulsory Reporting
Elder Abuse
 Staff education on Elder Abuse and Compulsory Reporting is conducted twice yearly and
during orientation for new staff.
 Staff are instructed to report immediately to the Home Manager at anytime should they
suspect abuse of any kind is occurring or if a resident/other person makes an allegation.
 If for some reason, staff do not feel able to report the matter to the Home Manager or to a
member of the senior management team then they may choose to report directly to the
Department of Health (Com) – Compulsory Reporting Line on 1800 081 549 (Com) or to the
police.
 All reports of suspected or alleged physical or sexual assault are to be thoroughly investigated
by the Home Manager or delegate. This includes all residents with cognitive impairment
making an allegation of physical or sexual abuse.
 All suspected incidents or allegations must be taken seriously and actioned as a Compulsory
Report.
 The Home Manager upon receiving a report of suspected or alleged sexual or physical
assault, shall contact the State General Manager immediately, or if unavailable, the Group
Quality Manager. The facts will be discussed to determine if the incident meets the legislative
requirements of a Compulsory Report and the required course of action will be implemented
by the Home Manager.
 If the State General Manager decides the incident should be reported to the Department, they
must first inform the Group Executive Care and Commercial.
Investigation on receipt of report:
The Home Manager or senior delegate will investigate the report by:
 Interviewing the person making the report and gathering all pertinent facts.
 Observing and if able, interviewing the resident/s involved.
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 Reviewing the Incident Report.

 Interviewing any other parties, as appropriate, who may have witnessed the incident.
 The Home Manager will ensure that the investigation and follow-up is fully documented.
 After discussion with the State General Manager (or delegate), if the incident meets the
legislative requirements and is a Compulsory Report, the Home Manager will contact:
o The residents Doctor and request direction re: their attendance or transfer of the resident
to an appropriate health care home.
o The residents’ representative and inform them of the suspicion or allegation and the
actions taken.
o The Police to lodge a report and request their attendance to investigate as soon as
practicable and within 24 hours of receiving the report.
 As soon as practicable after notifying the Police and within 24 hours of being made aware of
the suspected or alleged report
o Complete the Reportable Assault Report (Department of Health form) and email it
to compulsoryreports@health.gov.au . Attach this form to Incident Report kept in their
Incident Report folder.
o If unable to access a computer they are to contact The Department of Health (Com) on
Freecall: 1800 081 549 to lodge the Compulsory Report and email the completed form to
The Department of Health as soon as possible.
7.3  Under the Act (Section 63-1AA) a reportable assault is defined as unlawful sexual contact with
a resident of an aged care home; or unreasonable use of force on a resident of an aged care
home.
 An Incident Report should be completed as soon as practicable detailing in Part B:
o All immediate actions taken to ensure the safety and well-being of the residents involved in
the incident and other residents at the home (where appropriate),
o The findings of the investigation undertaken by the Home Manager (or delegate) and
o The changes and strategies put in place to prevent the incident occurring again.
 The assault will be recorded on the Compulsory Reporting Register on the homes G drive.
 The Incident Report for the assault should be attached to the Reportable Assault Report
(Dept. of Health form) and kept in the Incident folder.
 For Compulsory Reporting Incidents (discretion not to report); photocopies of the following
evidence should also be kept with the Incident Report in the incident folder:
o Evidence of assessed cognitive deficit dated prior to the incident
o Care Plan showing review (signature and date) within 24 hours of allegation.
 The Home Manager and the senior management team should take reasonable measures to
protect the identity of any staff member who makes a report and protect them from
victimisation.

7.4 Unexplained Resident Absence:

 Staff are instructed to report immediately to the Home Manager should a resident be
unaccountably missing from the home.
 Staff shall take all reasonable steps to locate the resident within the home and surrounding
areas or at known destinations.
 If a report is required to be lodged with the police because the resident cannot be found within
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a reasonable time or there are concerns for their safety, the Home Manager is to be consulted
immediately to authorise the report.
 The Home Manager shall ensure that the resident’s designated representative is notified of
the report to the police.
 The Home Manager should then contact the State General Manager.
 The State General Manager will inform the Group Executive Care and Commercial that the
police have been informed.
 The Home Manager will report all instances of an unexplained absence of a resident/or
missing resident that involved the police to the Department of Health within 24 hours of the
incident occurring:
o Complete the Unexplained Absence Report (Department of Health form) and email it
to compulsoryreports@health.gov.au . Attach this form to Incident Report kept in their
Incident Report folder.
o If unable to access a computer they are to contact The Department of Health (Com) on
Freecall: 1800 081 549 to lodge the Compulsory Report and email the form to The
Department of Health as soon as possible.
o The incident will be recorded on the Compulsory Reporting Register on the G drive.
 An Incident Report should also be completed as soon as practicable detailing in Part B:
o All immediate actions taken to ensure the safety and well being of the residents involved in
the incident
o The findings of the investigation undertaken by the Home Manager (or delegate) and
o The changes and strategies put in place to prevent the incident occurring again.
7.5 Reporting for Compulsory Reported incidents:
Following an investigation of the incident by the Home Manager (or delegate), the completed
Incident Report is to be emailed to the State General Manager and the home’s Quality Manager.
They will provide feedback regarding further investigation or actions that may be required.

7.6 Any Compulsory Reported Incident that results in injury or hospitalisation should be reported to
the insurer.
Part A of the Incident Report should be completed as per usual. This should be scanned and
emailed to ‘japara@marsh.com’ (insurance) as soon as practicable to notify them of the possibility
of a claim.

CRITICAL INCIDENT INVESTIGATION PROCEDURE

8.1 Immediately after an incident is thought to be “Critical” the Home Manager will notify the State
General Manager or delegate by telephone

8.2 A decision will be made by the State General Manager or delegate in consultation with the senior
management team re: legal advice being sought. If legal advice is required, it should be accessed
as soon as possible after the incident.

8.3 Part A of the Incident Report should be completed as per usual. This should be scanned and
emailed to ‘japara@marsh.com’ (insurance) as soon as practicable to notify them of the possibility
of a claim.
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8.4 An investigation is completed as soon as practicable after the incident by the Home Manager in
consultation with a member of the senior management team. This process should be thoroughly
documented in Part B of the Incident Report.

8.5 Reporting for critical incidents:

Following an investigation of the Critical Incident by the Home Manager (or delegate), the
completed Incident Report is to be emailed to the State General Manager and the home’s Quality
Manager.

They will provide feedback regarding further investigation or actions that may be required.

8.6 The Home Manager ensures that actions arising from the Critical Incident Investigation Report
are:

 Recorded on a Feedback Form or CI as appropriate.

 Reported on at the relevant meeting/s e.g. Staff, Hospitality.
 Reported on the Monthly Corporate Report
INCIDENT REPORT STATISTICS
9.1 PURPOSE
The incident statistics we collect are an integral part of our continuous improvement system.

Data is collected and collated on the Monthly Incident-Accident Report within 10 working days
following the end of each month both for individual residents and home wide in order to identify
and address trends and anomalies. The data is also collated and benchmarked within the
organisation to enable identification of areas requiring improvement across all facilities within the
group.

Benchmarking also enables the identification of facilities within the group who are performing well
ensuring staff receive the appropriate recognition for their efforts in providing high quality
outcomes for residents, staff and other stakeholders.

9.2 The Home Manager (or delegate) collates all incident reports and reports statistics at the
Staff/Medication Advisory Committee meetings.

9.3 After statistics are evaluated, issues raised are reviewed and any recommendations made; the
Home Manager (or delegate) will action these through the Feedback system as required.