§ 29.29 Incident reporting procedures.\n The commissioners of the office of mental health and the office for\npeople with developmental disabilities of the department shall establish\npolicies and uniform procedures for their respective offices for the\nreporting, compilation, and analysis of incident reports. Incident\nreports shall, for the purposes of this chapter, mean reports of\naccidents and injuries affecting patient health and welfare at\nfacilities. These policies and procedures shall include but shall not be\nlimited to:\n 1. The establishment of a patient care and safety team at the facility\nlevel which shall include but not be limited to a: physician, nurse,\nsocial worker and therapy aide, to investigate and report to the\nfacility director on:\n (i) suicides or attempted suicides;\n (ii) violent behavior exhibited by either patients or employees;\n (iii) frequency and severity of injuries incurred by either patients\nor employees;\n (iv) frequency and severity of injuries occurring on individual wards\nor in buildings at such facility;\n (v) patient leave without consent;\n (vi) medication errors; and\n (vii) recommendations for corrective actions in response to incident\nreports to ensure the care and safety of all patients.\n 2. The establishment of cumulative record keeping of incident reports\nwhich identifies patient and employee involvement.\n 3. A compilation of uniform and measurable information, first on a\nfacility basis, then on an office-wide basis, that will indicate where\nthe greatest number and types of incidents occur.\n 4. Each facility shall aggregate its data monthly for the director and\nthat aggregated information shall be submitted, at least semi-annually\nto the commissioner of the office of mental health and to the\ncommissioner of the office for people with developmental disabilities.\n 5. The commissioners shall transmit a copy of any report received\npursuant to subdivision four of this section to the state commission on\nquality of care and advocacy for persons with disabilities.\n
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