The document provides instructions for reporting incidents at a healthcare facility. It states that all incidents should be reported within 24 hours, and the employee's direct supervisor and any additional appropriate parties should be notified. The incident report has four parts: general information about the consumer and incident, details of the incident, type of occurrence, and a signature. It provides forms to fill out for each part, to collect information like consumer details, description of incident and injury, response taken, and parties notified.

1. Incident Reporting

2. Instructions
• All incidents should be reported within 24 hours unless the incident leads
to direct harm of the employee or patient which may require immediate
attention
• Employee’s direct supervisor should be notified of all incidents
• There are four parts to the incident report:
(all parts should be filled out as completely as possible)
Part 1 -Consumer, Incident, & Witness General Information
Part 2- Incident Details
Part 3- Type of Occurrence
Part 4- Signature

3. Part 1
PART 1: Consumer, Incident & Witness General Information
Consumer name: _______________________________________________________________
Address: ______________________________________________________________________
City: ________________________ State: _____ Zip: __________
Phone: _______________________________
Location of incident: ____________________________________________________________
Date of incident: ______________ Time incident occurred/ discovered: ___________
Witness name/phone: ____________________________________________________________
Witness name/phone: ____________________________________________________________
Consumer condition prior to occurrence: (select all that apply)
☐Alert/ oriented ☐Disoriented/confused ☐Sedated/medicated
☐Weak/dizzy ☐Combative/assaultive ☐Senile dementia/Alzheimer’s
☐Unconscious ☐Visually impaired ☐Hearing impaired
☐Walked w/device ☐Walked independently ☐Walked w/person(s)
☐Bed only ☐Chair only
☐Other (describe):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

4. Part 2
PART 2: Incident Details
Severity of incident -Provide a brief narrative description of incident (factual information only):
☐No apparent injury ☐Minor (first aid) ☐Moderate (fracture, sutures)
☐Severe (hospitalization ☐Death
Description of injury (if any): ____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Response to incident (select all that apply):
☐First aid ☐Consumer refused treatment ☐Called 911
☐Admitted to hospital ☐No intervention ☐Unknown
Provide further description, if necessary, of the actions you took in response to this incident:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Individuals Notified (select all that apply):
Supervisor/ manager
Name of individual notified: _____________________________________________________
Date/ time of notification: _______________________________________________________
Physician
Name of individual notified: _____________________________________________________
Date/ time of notification: _______________________________________________________
Family
Name of individual notified: _____________________________________________________
Date/ time of notification: _______________________________________________________

5. Part 3
PART 3: Type of Occurrence (select all that apply)
Fall Occurrence: ☐Observed ☐Not Observed
☐Found on floor ☐From toilet ☐While ambulating
☐During transfer ☐Out of bed ☐Eased to floor
☐Out of chair ☐Slip/trip ☐Out of wheelchair
☐Other (describe): __________________________________________________
Miscellaneous Occurrence: ☐Observed ☐Not Observed
☐Fire ☐Consumer refuses treatment
☐Burn ☐Unplanned absence of caregiver
☐Abuse ☐Caregiver and/or consumer issues
☐Complaints of theft ☐Home care staff & consumer disagreement
☐Damage to personal property ☐Safety issues
☐Other (describe): __________________________________________________
Equipment Occurrence: ☐Observed ☐Not Observed
Related to: ☐Fire ☐Consumer refuses treatment
☐Equipment malfunction ☐Catheter ☐Life-sustaining equipment
☐Implanted device ☐Infusion pump ☐Disposable device
☐IV ☐Other (describe): _____________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PART 3: Continued
Medical Occurrence: ☐Observed ☐Not Observed
☐Consumer error ☐Caregiver error ☐Employee error ☐Pharmacy error
Type of medication intake: ☐Oral ☐IM ☐IV
☐Other: _____________________________________________
Type of medication incident: ☐Adverse allergic reaction ☐Wrong medication
☐Extra dose ☐Wrong time ☐Wrong dose ☐Wrong routine
☐Missed dose ☐Late delivery ☐Mislabeled
☐Other (describe): _______________________________________________________________

6. Part 4
• Part 4: Signature of Person Completing this Form
•
• Signature: ___________________________________________
• Print name: __________________________________________
• Date: _____________________

7. Incident Report Log
Date Time Reported Person Reporting Type of Occurrence Supervisor Notified Report Completed
Incidents will be recorded in logbook by month/year
If no occurrences, it shall be noted by a diagonal line across the page and signed by appropriate authority