Did the person receive any blood thinners (if GI bleed)? 
If the fall was not observed, did staff move the individual? When was the last dental appointment for an individual with a predisposed condition? What is the pertinent staff training? What was the content of the MOLST order? Did staff report per policy, per plans, and per training? What were the directions for calling a nurse? Were they followed or not? Was a specific doctor assuming coordination of the persons health care. Were the decisions in the person'sbest interest?
Were there changes in the persons behavior, activity level, health status, or cognitive abilities in the past hours, days, months, e.g. Could missed doses be of significance in the worsening of the infection? Did the person have an injury or illness that impaired mobility? Were the risks addressed? Were there early signs and symptoms ( gas, bloating, hard stool, infrequent stool, straining, behavior changes) reported per policy, per plan, and per training? Were there signs that nursing staff were actively engaged in the case? Any predispositions? Were staff trained on the PONS? What did the bowel records show? Specialist care, per recommendations? Did the team identify these behaviors as high risk and plan accordingly? Was there a diagnosed infection under treatment at home? Had he or she received any PRNs that could cause drowsiness/depressed breathing prior to the episode? What was the latest prognosis? Use these questions, as appropriate. What is the policy for training? Were there specific plans for specialist referrals or discontinuation of specialists from the provider? Was the fall observed? 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 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.)? Was the preventative health care current and adequate? 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 this reported? Was it up-to-date? 
Diet orders and swallow evaluation, if relevant. Did the person receive sedation related to a medical procedure? Who was the doctor/provider managing the illness? Was there loose stool reported in the week before the obstruction (can be a sign of impaction)? Previous episodes? 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 any previous swallowing evaluations and when were they? Is it known whether the person hit his or her head during the fall? What was the infection? 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)? is gene dyrdek still alive. When was his or her last lab work (especially if acute event)? As a 
They are not diseases or causes of death, but rather circumstances. Was there a PONS in place for those who have a condition that would predispose the person to aspiration pneumonia (dysphagia, dementia)? When was the last blood level done for medication levels? 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 Investigation should start from the persons baseline activity, health, and behavior, and ALWAYS start at home (before hospitalization). Severity? When was the last neurology appointment? If so, what guidelines? 
Was it provided? Did it occur per practitioners recommendations? Certify notifications made and no objections. Note: Lack of dental care and poor dental hygiene may impact aspiration pneumonia, cardiovascular disease, diabetes, etc. 911? %PDF-1.6
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WebProviding High-Quality Supports and Services. How and when was the acute issue identified? 
OPWDD - What does OPWDD stand for? at the mall, picnic, or bedroom)? Were staff involved trained? Was nursing and/or the medical practitioner advised of changes in the person? Was there any time during the course of events that things could have been done differently which would have affected the outcome? 
Artificial hydration/ nutrition? Was it communicated? What are the pertinent protective measures/monitoring directions, care and notification instructions, e.g. 
Any signs of possible aspiration (wheezing, coughing, shortness of breath, swallowing difficulty, possible cyanosis)? Were staff trained? Other? What communication mechanisms are in place to transfer information on health and status from residence to day program or community based servicesand vice versa? Did staff follow plans in the non-traditional/community setting? 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 Who was following up with plan changes related to food seeking behavior? What were the PONS in place at the time? Were appointments attended per practitioners recommendations? Were appointments attended per practitioners recommendations? 
Did plan address Pica as a choking risk? What was the course of stay and progression of disease? WebIndividual Plan of Protective Oversight. If seizures occurred, what was the frequency? Circumstances? Dining behavior risk e.g. (CDC.gov, 2014) Most often people are in the hospital when they die from sepsis. 
hb```%\@9V6]h Were appointments attended per practitioners recommendations? Documentation related to the plan, if required. Webgwen araujo brother; do male actors wear lipstick. Confirm the person's lack of capacity to make health care decisions. consistency, support, storage, positioning? Stop/reduce a bowel medication? 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. Seizure? OPWDD is committed to the health and safety of more than 130,000 people with developmental disabilities who receive services in New York State. 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)? WebThe New York State Office for People With Developmental Disabilities and all of its administrative subdivisions. Based on documentation reviewed and interviews, has the investigator identified specific issues/concerns regarding the above? What communication occurred between OPWDD service provider and hospital? Life Plan/CFA and relevant associated plans. Facilitate individuals learning and skill training in fire safety. 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. When was his or her last consultation with a cardiologist? Any changes in medications prior to the acute incident? WebEnsure appropriate supervision, health and safety of individuals; Implement Individual Plan of Protective Oversight. 690 0 obj
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Please visit the Choking Initiative webpage. 
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<. Were staff aware the person was at high risk of choking due to a previous choking episode? Did the person start a narcotic pain medication? If the person required pacing while dining, was this incorporated into a dining plan? 
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. What are the pertinent agency policies and procedures? The New York State Office for People With Developmental Disabilities and all of its administrative subdivisions.
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 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 If so, was it followed and documented? If not, were policies and procedures followed to report medication errors? If fluids are to be given, how much? The Free Dictionary. Which doctor was coordinating the health care? Was there a known mechanical swallowing risk? 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? Had the person received sedative medication prior to the fall? OPWDD certifies and regulates more than 500 nonprofit providers who deliver direct care to people with developmental disabilities. Was there evidence of MD or RN oversight of implementation? Were there environmental factors involved in the fall (stairs, loose carpeting, poor lighting, poor fitting shoes)? Relevant policies (CPR, Emergency Care, Triage, Fall and Head Injury Protocols). Was food taking/sneaking/stealing managed? 
Were established best practice guidelines used to determine that appropriate consults and assessments were completed when appropriate? 
Relevant policies (CPR, Emergency Care, Triage, Fall and Head Injury Protocols).
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opwdd plan of protective oversight