A Case Manager monitors and assesses ongoing services in the home. We also "monitor" what is going on with the client and anything out of the ordinary is to be reported to the case manager. If an incident occurs the person (aide, home maker, meals delivery) that discovers the incident has to report it with in 24 hours of the incident. Since the case manager has a history of the client we get to do the incident report follow ups. Our case notes are entered into a system that allows all the other case managers, supervisor in all offices and the state to review.
It is especially important to have a history of case notes when an incident report is made. When something happens to the clients such as theft, fall, or nursing home placement an incident report must be made to the state for review.
The following information must be added:
Cite the date
Identify the people and relationship
Identify the type of contact – face to face, phone conversation, etc.
Describe the event
Recount the transaction
Demonstrate how the contact relates to the ISP
Describe how the issue was resolved and/or next steps
Case Manager went to clients home on 3/22/10. While visiting the cm noticed a large bruise on clients right arm. Client is an 89 year old female with hypertension, diabetes, macular degeneration and amputation of both legs. Client lives in a one bedroom apartment with her daughter and her autistic 8 year old. The client said that her LPN dropped her while getting out of the bath tub a couple of days ago. The client did not want the LPN to get in trouble so she did not tell anyone. The home was neat and clean. The client was dressed in clean clothes and had good personal hygiene. CM followed up with unit manager at Sunshine Valley Care and Nurse Suzy will speak with LPN Brandy today at 2:00pm. CM will follow up with client and Nurse Suzy for further information regarding incident.
Nurse Suzy followed up with LPN Brandy on 3/22/10. Brandy said the bruise was on clients arm already when she came to give her a bath. Brandy asked client about bruise and client said she hit it on the kitchen door. Brandy noted that client has had other bruises on her body during the last 3 months but did not know she had to report it because the client told her not to. CM contacted Adult Protective Services to report bruising. APS went into the home on 3/25/10.
Follow up required in 7 days
Follow up 2: 3/28/10
Case manager followed up with APS on 3/25/10. Client was very hesitant and fearful to admit that daughter does "push her around". Client does not want to leave her home. Nurse Suzy has educated LPN on signs of abuse and how/when to report an incident. Case Manager has added respite hours for the daughter to get away and have some time to herself. The client is not pressing any charges against the daughter. The daughter has agreed to attend a caregiver workshop to help her deal with caring for her mother.
4/15/10 Case closed
All follow ups are required to be filed by the cm. The first person to see the incident is to be the first to report. Since the cm only goes into the home every 3 months we do not do all the initial reports but have to follow up on all the reports made for our clients.