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Nursing Home Facility Incident Report
Current
Incident Overview
Outside Agency Questions
Complete
Instructions
Important!
An incident report cannot be saved and completed later.
Once started, the incident report must be submitted prior to closing the internet browser.
Otherwise, the reported data will be erased.
Overview Questions
Facility Name
Facility ID (PFI)
Please enter the PFI for the Nursing Home
Program ID (ADHCP)
If facility type is ADHCP please enter the full Program ID
Contact person
Contact Person HCS ID
Please enter the User ID that you use to access the New York State Health Commerce System
Contact Person Title
Contact Person Phone Number
Contact Person E-Mail Address
Contact Person E-Mail Address
For case number and acknowledgement only
Confirm email
Allegation Type
Select all applicable incident types
Physical Abuse
Sexual Abuse
Mental/Verbal Abuse
Deprivation of Goods and Services by Staff
Neglect
Misappropriation of Resident Property/Exploitation
Injury of Unknown Source
Suspected Crime
Physical Plant or environment (loss of service, fire, smoke, flood, or other similar incident)
Elopement
Other (Death by other than natural causes, attempted suicide, accidents, choking, medication errors, other quality of care)
Is there reasonable cause to believe that abuse, neglect or mistreatment occurred?
- Select -
Yes
No
Undetermined
Was the incident a result of a care plan violation?
- Select -
Yes
No
Is the facility investigation complete?
- Select -
Yes
No
Incident location
Incident date/time
Incident date/time: Date
Incident date/time: Time
Date/Time staff first made aware of the incident
Date/Time staff first made aware of the incident: Date
Date/Time staff first made aware of the incident: Time
Date/Time administrator first made aware of the incident
Please leave blank if Administrator has not been made aware.
Date/Time administrator first made aware of the incident: Date
Date/Time administrator first made aware of the incident: Time
Elopement details
Was this incident an elopement?
- Select -
Yes
No
Was the resident considered an elopement risk?
- Select -
Yes
No
Date/Time last seen before elopement
Date/Time last seen before elopement : Date
Date/Time last seen before elopement : Time
Date/Time noted missing
Date/Time noted missing : Date
Date/Time noted missing : Time
Did the system to prevent elopement function properly?
- Select -
Yes
No
Has the resident returned to the facility?
- Select -
Yes
No
Incident Overview
Describe the incident, including any injury or psychological harm to resident(s): Please use last names to identify residents in all answers on this section
Whether serious bodily injury occurred, if known
Describe any type of injury such as a bruise, scratch, laceration, puncture wound, fracture, bleeding, redness on the skin, etc.
Describe any changes in the resident’s behavior that indicate something different from the resident’s normal baseline such as crying, expressions or displays of fear, cowering, anger, withdrawal, difficulty sleeping, etc.
Describe the investigation findings to date:
Describe the facility's immediate response and plan to prevent recurrence, including any change in policy / procedure and action taken in regard to staff: *
Resident Information
If you are listing more than 2 residents you will only need to provide their name and room number. Other information deemed necessary by DOH will be requested by the investigator.
How many residents were involved?
- Select -
0
1
2
More than 2 - Entire floor/unit/building
First resident involved:
Last Name:
First Name:
Date of Birth
Current location:
Is this resident a victim, perpetrator or other?
- Select -
Victim
Perpetrator
Other
Primary diagnoses:
Descriptions of co-morbidities; medical history; disciplinary history; etc.
BIMS Score:
- Select -
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
99
Second resident involved:
Last name
First name
Date of birth
Current location
Is this resident a victim, perpetrator or other?
- Select -
Victim
Perpetrator
Other
Primary diagnoses
Descriptions of co-morbidities; medical history; disciplinary history; etc.
BIMS Score:
- Select -
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
99
Additional resident names and room numbers:
Non-Resident Perpetrator
Non-residents are employees, vendors, third parties, and individuals not residing in facility suspected of abuse, neglect, mistreatment, or misappropriation. They are not witnesses, interviewed staff, visitors, or resident aggressors.
How many non-residents were accused of abuse, mistreatment, neglect, or misappropriation?
- Select -
0
1
2
More than 2
First accused perpetrator:
Last Name:
First name
Title:(if Staff, else N/A)
Does the perpetrator still have contact with residents?
- Select -
Yes
No
Does the perpetrator have prior history of care plan violations?
- Select -
Yes
No
Second accused perpetrator
Last name
First name
Title (if staff, else N/A)
Does the perpetrator still have contact with residents?
- Select -
Yes
No
Does the perpetrator have prior history of care plan violations?
- Select -
Yes
No
List additional perpetrator names, titles, relationship, etc.:
Witness Information
How many witnesses were there?
- Select -
0
1
2
More than 2
First witness:
Last name:
First name:
Witness phone number:
Is this witness staff?
- Select -
Yes
No
Title:(if Staff, else N/A)
Relationship to victim:
Second witness
Last name
First name
Witness phone number:
Is this witness staff?
- Select -
Yes
No
Title (if staff, else N/A)
Relationship to victim
List additional accused witness names, contact information, and titles or relationships
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