Final Report Templates

Facility Name:

Occurrence ID:

Victim Information

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence :

5. Provide physical status as relevant to this occurrence:

6. Does the victim have a history of behaviors? (Yes/No)

   1. If yes, Provide a description of the behaviors:

   2. Is there a care plan for the victim's behaviors? (Yes/No)

   3. If yes, Provide a summary of the care plan

7. Has the victim been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, Provide the occurrence numbers, types, and dates:

Alleged Assailant Information

1. Relationship to licensee (consumer, staff member, other service provider, family, visitor, other/unknown)

Alleged Assailant - Consumer

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence:

5. Provide physical status as relevant to this occurrence:

6. Does the alleged assailant have a history of behaviors? (Yes/No)

   1. If yes, provide a description of the behaviors:

   2. Is there a care plan for the alleged assailant's behaviors? (Yes/No)

   3. If yes, provide a summary of the care plan

7. Has the alleged assailant been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, provide the occurrence numbers, types, and dates:

Alleged Assailant - Staff Member or Other Service Provider

1. ID/Name of Staff Member:

2. Gender

3. Title

4. License/Certification Number:

5. Were background checks completed? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why background checks were not conducted:

6. Were reference checks completed on the staff person? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why reference checks were not conducted:

7. Has the staff member been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, Provide the occurrence numbers, types, and dates:

Alleged Assailant - Family, Visitor or Other/Unknown

1. Describe:

Description

1. Describe what occurred:

2. Was the occurrence witnessed?

   1. If yes, who witnessed the occurrence? (Staff, Visitor, Consumer, Other)

   2. If consumer or staff, provide name/ID:

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. Was the victim assessed? (Yes/No)

   1. If yes:

      1.  Who conducted an assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why the victim was not assessed:

5. Was treatment provided to the victim? (Yes/No)

   1. If yes:

      1. Describe the treatment:

6. Was the victim transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. What treatment was provided?

      3. Did the victim return to the previous level of care?

7. Current status of victim:

8. Was the victim interviewed? (Yes/No)

   1. If yes:

      1. Provide the results of the interview:

   2. If no:

      1. Why was the victim not interviewed?

9. Describe any non-verbal responses and/or behavioral changes observed:

10. Was the alleged assailant interviewed by management? (Yes/No)

    1. If yes:

       1. Provide results of interview:

11.  Provide a brief summary of the interviews conducted with other consumers and staff as relevant to the investigation

12.  Provide the results of documentation review

13.  Were policies and procedures followed? (Yes/No)

    1. If no:

       1. Describe deviation from policies and procedures:

14.  Provide the conclusion of the internal investigation:

Facility Actions

1. Describe any changes made to the victim's treatment regimen and/or care plan as a result of the occurrence:

2. If alleged assailant was a consumer:

   1. What changes were made to the alleged assailant's treatment regimen and/or care plan as a result of the occurrence?

3. If alleged assailant was a staff member or other service provider:

   1. In response to the conclusion of the investigation, what actions were taken with the alleged assailant?

4. Describe interventions that were put into place to help prevent a recurrence:

Notifications

1. Who was notified of the occurrence? 

   1. All allegations of abuse must be reported to the police; please provide the date/time of police notification and police case number:

   2. Other (Family/Guardian, physician, Ombudsman, Adult Protective Services, Board of Nursing, etc.):

Facility Name:

Occurrence ID:

Victim Information

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence :

5. Provide physical status as relevant to this occurrence:

6. Does the victim have a history of behaviors? (Yes/No)

   1. If yes, Provide a description of the behaviors:

   2. Is there a care plan for the victim's behaviors? (Yes/No)

   3. If yes, Provide a summary of the care plan

7. Has the victim been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, Provide the occurrence numbers, types, and dates:

Alleged Assailant Information

1. Relationship to licensee (consumer, staff member, other service provider, family, visitor, other/unknown)

Alleged Assailant - Consumer

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence:

5. Provide physical status as relevant to this occurrence:

6. Does the alleged assailant have a history of behaviors? (Yes/No)

   1. If yes, provide a description of the behaviors:

   2. Is there a care plan for the alleged assailant's behaviors? (Yes/No)

   3. If yes, provide a summary of the care plan

7. Has the alleged assailant been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, provide the occurrence numbers, types, and dates:

Alleged Assailant - Staff Member or Other Service Provider

1. ID/Name of Staff Member:

2. Gender

3. Title

4. License/Certification Number:

5. Were background checks completed? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why background checks were not conducted:

6. Were reference checks completed on the staff person? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why reference checks were not conducted:

7. Has the staff member been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, Provide the occurrence numbers, types, and dates:

Alleged Assailant - Family, Visitor or Other/Unknown

1. Describe:

Description

1. Describe what occurred:

2. Was the occurrence witnessed?

   1. If yes, who witnessed the occurrence? (Staff, Visitor, Consumer, Other)

   2. If consumer or staff, provide name/ID:

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. Was the victim assessed? (Yes/No)

   1. If yes:

      1.  Who conducted an assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why the victim was not assessed:

5. Was treatment provided to the victim? (Yes/No)

   1. If yes:

      1. Describe the treatment:

6. Was the victim transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. What treatment was provided?

      3. Did the victim return to the previous level of care?

7. Current status of victim:

8. Was the victim interviewed? (Yes/No)

   1. If yes:

      1. Provide the results of the interview:

   2. If no:

      1. Why was the victim not interviewed?

9. Describe any non-verbal responses and/or behavioral changes observed:

10. Was the alleged assailant interviewed by management? (Yes/No)

    1. If yes:

       1. Provide results of interview:

11.  Provide a brief summary of the interviews conducted with other consumers and staff as relevant to the investigation

12.  Provide the results of documentation review

13.  Were policies and procedures followed? (Yes/No)

    1. If no:

       1. Describe deviation from policies and procedures:

14.  Provide the conclusion of the internal investigation:

Facility Actions

1. Describe any changes made to the victim's treatment regimen and/or care plan as a result of the occurrence:

2. If alleged assailant was a consumer:

   1. What changes were made to the alleged assailant's treatment regimen and/or care plan as a result of the occurrence?

3. If alleged assailant was a staff member or other service provider:

   1. In response to the conclusion of the investigation, what actions were taken with the alleged assailant?

4. Describe interventions that were put into place to help prevent a recurrence:

Notifications

1. Who was notified of the occurrence? 

   1. All allegations of abuse must be reported to the police; please provide the date/time of police notification and police case number:

   2. Other (Family/Guardian, physician, Ombudsman, Adult Protective Services, Board of Nursing, etc.):

Facility Name:

Occurrence ID:

Victim Information

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence :

5. Provide physical status as relevant to this occurrence:

6. Does the victim have a history of behaviors? (Yes/No)

   1. If yes, Provide a description of the behaviors:

   2. Is there a care plan for the victim's behaviors? (Yes/No)

   3. If yes, Provide a summary of the care plan

7. Has the victim been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, Provide the occurrence numbers, types, and dates:

Alleged Assailant Information

1. Relationship to licensee (consumer, staff member, other service provider, family, visitor, other/unknown)

Alleged Assailant - Consumer

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence:

5. Provide physical status as relevant to this occurrence:

6. Does the alleged assailant have a history of behaviors? (Yes/No)

   1. If yes, provide a description of the behaviors:

   2. Is there a care plan for the alleged assailant's behaviors? (Yes/No)

   3. If yes, provide a summary of the care plan

7. Has the alleged assailant been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, provide the occurrence numbers, types, and dates:

Alleged Assailant - Staff Member or Other Service Provider

1. ID/Name of Staff Member:

2. Gender

3. Title

4. License/Certification Number:

5. Were background checks completed? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why background checks were not conducted:

6. Were reference checks completed on the staff person? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why reference checks were not conducted:

7. Has the staff member been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, Provide the occurrence numbers, types, and dates:

Alleged Assailant - Family, Visitor or Other/Unknown

1. Describe:

Description

1. Describe what occurred:

2. Was the occurrence witnessed?

   1. If yes, who witnessed the occurrence? (Staff, Visitor, Consumer, Other)

   2. If consumer or staff, provide name/ID:

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. Was the victim assessed? (Yes/No)

   1. If yes:

      1.  Who conducted an assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why the victim was not assessed:

5. Was treatment provided to the victim? (Yes/No)

   1. If yes:

      1. Describe the treatment:

6. Was the victim transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. What treatment was provided?

      3. Did the victim return to the previous level of care?

7. Current status of victim:

8. Was the victim interviewed? (Yes/No)

   1. If yes:

      1. Provide the results of the interview:

   2. If no:

      1. Why was the victim not interviewed?

9. Describe any non-verbal responses and/or behavioral changes observed:

10. Was the alleged assailant interviewed by management? (Yes/No)

    1. If yes:

       1. Provide results of interview:

11.  Provide a brief summary of the interviews conducted with other consumers and staff as relevant to the investigation

12.  Provide the results of documentation review

13.  Were policies and procedures followed? (Yes/No)

    1. If no:

       1. Describe deviation from policies and procedures:

14.  Provide the conclusion of the internal investigation:

Facility Actions

1. Describe any changes made to the victim's treatment regimen and/or care plan as a result of the occurrence:

2. If alleged assailant was a consumer:

   1. What changes were made to the alleged assailant's treatment regimen and/or care plan as a result of the occurrence?

3. If alleged assailant was a staff member or other service provider:

   1. In response to the conclusion of the investigation, what actions were taken with the alleged assailant?

4. Describe interventions that were put into place to help prevent a recurrence:

Notifications

1. Who was notified of the occurrence? 

   1. All allegations of abuse must be reported to the police; please provide the date/time of police notification and police case number:

   2. Other (Family/Guardian, physician, Ombudsman, Adult Protective Services, Board of Nursing, etc.):

Facility Name:

Occurrence ID:

Consumer Information

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence :

5. Provide physical status as relevant to this occurrence:

6. Did the consumer have a known history of falls? (Yes/No)

   1. If yes:

      1. Describe safety interventions:

Description

1. Describe what occurred:

2. Was the occurrence witnessed?

   1. If yes, who witnessed the occurrence? (Staff, Visitor, Consumer, Other)

   2. If consumer or staff, provide name/ID:

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. Was the consumer assessed? (Yes/No)

   1. If yes:

      1. Who conducted an assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why the victim was not assessed:

4. Was treatment provided to the consumer? (Yes/No)

   1. If yes:

      1. Describe the treatment:

5. Was the consumer transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. Describe what diagnostic tests were conducted and the results:

      3. What treatment was provided?

      4. Did the consumer return to the previous level of care?

6. Current status of consumer, including any functional status changes:

7. Provide results of documentation review and interviews

8. Were safety interventions followed? 

9. Were policies and procedures followed?

10.  Provide the conclusion of the internal investigation

Facility Actions

1. Describe any changes made to the consumer's treatment regimen and/or care plan as a result of the occurrence

2. Describe interventions that were put into place to help prevent a recurrence

Notifications:

1. Who was notified of the occurrence? (Police, physician, family/guardian, etc.)

Facility Name:

Occurrence ID:

Consumer Information

1. Decedent full name:

2. Gender:

3. Date of Birth:

4. Age at the time of occurrence:

5. Provide decedent’s medical history:

Description

1. Describe what occurred:

2. Decedent date of death:

3. County where death occurred:

4. Was the consumer receiving hospice services at the time of death? (Yes/No)

5. Did the coroner release the body? (Yes/No)

6. Coroner’s Name:

7. Was the death a suicide? (Yes/No)

   1. If yes:

      1. Was the consumer exhibiting suicidal ideation and/or gestures?

      2. If yes, describe suicide precautions in place:

8. Was the death the result of a restraint? (Yes/No)

9. Was the occurrence witnessed?

   1. If Yes, by whom?

Investigation

1. Date investigation started:

2. Describe the investigative actions taken.

3. Did the consumer have advance directives? (Yes/No)

   1. If yes:

      1. Describe advance directives:

      2. Were the advance directives followed? (Yes/No)

      3. If not, describe the deviation and why they were not followed:

4. Is an autopsy being done?

5. Provide results of documentation review and interviews:

6.  Were policies and procedures followed? (Yes/No)

   1. If no:

      1. Describe deviation from policies and procedures:

7.  Provide the conclusion of the internal investigation:

Facility Actions

1. Describe interventions that were put into place to help prevent a recurrence:

Notifications

1. Who was notified of the occurrence? (Police, physician, family/guardian, coroner, etc.)

Facility Name:

Occurrence ID:

Consumer Information

1. Name/ID:

2. Gender:

3. Date of Birth:

4. Age at the time of occurrence:

5. Provide medical history as relevant to this occurrence:

Alleged Assailant Information

1. Relationship to licensee (consumer, staff member, other service provider, family, visitor, other/unknown):

Alleged Assailant - Staff Member or Other Service Provider

1. ID/Name of Staff Member:

2. Gender

3. Title

4. License/Certification Number:

5. Were background checks completed? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why background checks were not conducted:

6. Were reference checks completed on the staff person? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why reference checks were not conducted:

7. Has the staff member been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, Provide the occurrence numbers, types, and dates:

8. Were any suspicious behaviors observed?

   1. If yes, describe:

Alleged Assailant - Consumer

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence:

5. Provide physical status as relevant to this occurrence:

6. Does the alleged assailant have a history of behaviors? (Yes/No)

   1. If yes, provide a description of the behaviors:

   2. Is there a care plan for the alleged assailants behaviors? (Yes/No)

   3. If yes, provide a summary of the care plan

7. Has the alleged assailant been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, provide the occurrence numbers, types, and dates:

8. Were any suspicious behaviors observed?

   1. If yes, describe:

Alleged Assailant - Family, Visitor, Other/Unknown

1. Describe:

Description

1. Describe what occurred:

2. Describe the medication involved in the diversion including name, quantity and form of the medication

3. Is the medication injectable? (Yes/No)

   1. If yes:

      1. What was the physician order?

      2. Provide the full name and date of birth of the staff person involved:

4. Did the consumer receive medication as prescribed? (Yes/No)

   1. If no:

      1. Describe any adverse effects as a result of the diversion:

5. Describe any other potential for patient harm:

6. Where was the medication stored?

7. Was the occurrence witnessed? (Yes/No)

   1. If yes, who witnessed the occurrence? (Staff, Visitor, Consumer, Other)

   2. If consumer or staff, provide name/ID:

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. Was the consumer assessed? (Yes/No)

   1. If yes:

      1. Who conducted an assessment?

      2. When was an assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why consumer was not assessed

5. Was treatment provided to the consumer? (Yes/No)

   1. If yes:

      1. Describe the treatment:

6. Was the alleged assailant interviewed by management? (Yes/No)

   1. If yes:

      1. Provide results of interview:

7. Provide a brief summary of the interviews conducted with other consumers and staff as relevant to the investigation:

8. Provide the results of documentation review:

9. Was drug screening of staff conducted? (Yes/No)

   1. If yes:

      1. What were the results of the drug screen?

      2. When was the drug screen conducted?

   2. If no:

      1. Why was the drug screening not conducted?

10. Were policies and procedures followed? (Yes/No)

    1. If no:

       1. Describe deviation from policies and procedures:

11.  Provide the conclusion of the internal investigation:

Facility Actions:

1. Describe any changes made to the consumer's treatment regimen and/or care plan as a result of the occurrence:

2. Describe interventions that were put into place to help prevent a recurrence

Notifications

1. Who was notified of the occurrence? (Police, physician, family/guardian, FDA, DEA, Board of Nursing, Board of Medical Examiners, etc.)

Facility Name:

Occurrence ID:

Consumer Information

1. Name/ID:

2. Gender:

3. Date of Birth:

4. Age at the time of occurrence:

5. Provide cognitive status as relevant to this occurrence

6. Provide physical status as relevant to this occurrence

Description

1. Describe what occurred:

2. How was the equipment being used?

3. Was the equipment removed from service? (Yes/No)

   1. If yes:

      1. Provide dates removed and put back into service:

4. Was the equipment inspected? (Yes/No)

   1. If yes:

      1. Who inspected equipment?

      2. What were the results of the equipment inspection?

5. Equipment type and age:

6. Equipment Serial Number:

7. Equipment Model Number:

8. Manufacturer's Name, Address, and Phone Number:

9. Describe any previous problems encountered with this equipment:

10.  Who maintains the equipment?

11.  Date of last service/preventive maintenance:

12.  Who performed last service/preventive maintenance?

13.  Was the occurrence witnessed?

    1. If yes, by whom?

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. Was the consumer assessed? (Yes/No)

   1. If yes:

      1.  Who conducted an assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why the consumer was not assessed:

5. Was treatment provided to the consumer? (Yes/No)

   1. If yes:

      1. Describe the treatment:

6. Was the consumer transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. What treatment was provided?

      3. Did the consumer return to the previous level of care?

7. Current status of consumer:

8. Provide a brief summary of the interviews conducted with other consumers and staff as relevant to the investigation:

9. Provide the results of documentation review:

10.  Were policies and procedures followed? (Yes/No)

    1. If no:

       1. Describe deviation from policies and procedures:

11. Were manufacturer and/or facility guidelines being applied? (Yes/No)

    1. If no:

       1. Describe deviation:

12.  Provide the conclusion of the internal investigation:

Facility Actions

1. Describe interventions that were put into place to help prevent a recurrence:

Notifications

1. Who was notified of the occurrence? (Physician, family/guardian, manufacturer, FDA, DEA, Board of Nursing, Board of Medical Examiners, etc.)

Facility Name:

Occurrence ID:

Consumer Information

1. Name/ID:

2. Gender:

3. Date of Birth:

4. Age at the time of occurrence:

5. Provide cognitive status as relevant to this occurrence

6. Provide physical status as relevant to this occurrence

Description

1. Describe what occurred:

2. Was the equipment removed from service? (Yes/No)

   1. If yes:

      1. Provide dates removed and put back into service:

3. Was the equipment inspected? (Yes/No)

   1. If yes:

      1. Who inspected equipment?

      2. What were the results of the equipment inspection?

4. Was the occurrence witnessed?

   1. If yes, by whom?

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. Was the consumer assessed? (Yes/No)

   1. If yes:

      1.  Who conducted an assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why the consumer was not assessed:

5. Was treatment provided to the consumer? (Yes/No)

   1. If yes:

      1. Describe the treatment:

6. Was the consumer transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. What treatment was provided?

      3. Did the consumer return to the previous level of care?

7. Current status of consumer:

8. Provide a brief summary of the interviews conducted with other consumers and staff as relevant to the investigation:

9. Provide the results of documentation review:

10.  Were policies and procedures followed? (Yes/No)

    1. If no:

       1. Describe deviation from policies and procedures:

11. Were manufacturer and/or facility guidelines being applied? (Yes/No)

    1. If no:

       1. Describe deviation:

12. Was the user properly trained in using the equipment? (Yes/No)

    1. If yes:

       1. Date of last training:

       2. How was competency demonstrated? 

    2. If no:

       1. Why was training not provided?

13. Has the staff member/provider been involved in similar occurrences in the past 12 months?

14.  Provide the conclusion of the internal investigation:

Facility Actions

1. In response to the conclusion of the investigation, what actions were taken with the staff member?

2. Describe interventions that were put into place to help prevent a recurrence:

Notifications:

1. Who was notified of the occurrence? (Physician, family/guardian, manufacturer, FDA, DEA, Board of Nursing, Board of Medical Examiners, etc.)

Facility Name:

Occurrence ID:

Consumer Information

1. Name/ID:

2. Gender:

3. Date of Birth:

4. Age at the time of occurrence:

5. Provide cognitive status as relevant to this occurrence

6. Provide physical status as relevant to this occurrence

7. Did the consumer have a known history of anesthesia complication or reaction? 

   1. If yes, describe:

Description

1. Describe what occurred:

2. Describe the procedure being performed:

3. Describe the anesthesia agent(s) involved:

4. Describe the reaction or complication:

5. When was the reaction or complication discovered?

6. Who discovered the reaction or complication?

7. Was the occurrence witnessed?

   1. If yes, by whom?

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. Was the consumer assessed? (Yes/No)

   1. If yes:

      1.  Who conducted an assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why the consumer was not assessed:

5. Was treatment provided to the consumer? (Yes/No)

   1. If yes:

      1. Describe the treatment:

6. Was the consumer transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. What treatment was provided?

      3. Did the consumer return to the previous level of care?

7. Current status of consumer:

8. Provide a brief summary of the interviews conducted with other consumers and staff as relevant to the investigation:

9. Provide the results of documentation review:

10.  Were policies and procedures followed? (Yes/No)

    1. If no:

       1. Describe deviation from policies and procedures:

11. Were manufacturer and/or facility guidelines being applied? (Yes/No)

    1. If no:

       1. Describe deviation:

12.  Provide the conclusion of the internal investigation:

Facility Actions

1. Describe any changes made to the consumer’s treatment regimen and/or care plan as a result of the occurrence:

2. Describe interventions that were put into place to help prevent a recurrence:

Notifications

1. Who was notified of the occurrence? (Physician, family/guardian, manufacturer, FDA, DEA, Board of Nursing, Board of Medical Examiners, etc.)

Facility Name:

Occurrence ID:

Consumer Information

1. Name/ID:

2. Gender:

3. Date of Birth:

4. Age at the time of occurrence:

5. Provide cognitive status as relevant to this occurrence

6. Provide physical status as relevant to this occurrence

7. Did the consumer have a known history of transfusion reaction? 

   1. If yes, describe:

Description

1. Describe what occurred:

2. When was the reaction or error discovered?

3. Who discovered the reaction or error?

4. Was the occurrence witnessed?

   1. If yes, by whom?

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. Was the consumer assessed? (Yes/No)

   1. If yes:

      1.  Who conducted an assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why the consumer was not assessed:

5. Was treatment provided to the consumer? (Yes/No)

   1. If yes:

      1. Describe the treatment:

6. Was the consumer transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. What treatment was provided?

      3. Did the consumer return to the previous level of care?

7. Current status of consumer:

8. Provide a brief summary of the interviews conducted with other consumers and staff as relevant to the investigation:

9. Provide the results of documentation review:

10.  Were policies and procedures followed? (Yes/No)

    1. If no:

       1. Describe deviation from policies and procedures:

11. Were manufacturer and/or facility guidelines being applied? (Yes/No)

    1. If no:

       1. Describe deviation:

12.  Provide the conclusion of the internal investigation:

Facility Actions

1. Describe interventions that were put into place to help prevent a recurrence:

Notifications

1. Who was notified of the occurrence? (Physician, family/guardian, manufacturer, FDA, DEA, Board of Nursing, Board of Medical Examiners, etc.)

Facility Name:

Occurrence ID:

Consumer Information

1. Name/ID:

2. Gender:

3. Date of Birth:

4. Age at the time of occurrence:

5. Provide cognitive status as relevant to this occurrence

6. Provide physical status as relevant to this occurrence

Alleged Assailant Information

1. Relationship to licensee (consumer, staff member, other service provider, family, visitor, other/unknown):

Alleged Assailant - Consumer

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence:

5. Provide physical status as relevant to this occurrence:

6. Does the alleged assailant have a history of behaviors? (Yes/No)

   1. If yes, Provide a description of the behaviors:

   2. Is there a care plan for the alleged assailant's behaviors? (Yes/No)

   3. If yes, Provide a summary of the care plan

7. Has the alleged assailant been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, Provide the occurrence numbers, types, and dates:

Alleged Assailant - Staff Member or Other Service Provider

1. ID/Name of Staff Member:

2. Gender

3. Title

4. License/Certification Number:

5. Were background checks completed? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why background checks were not conducted:

6. Were reference checks completed on the staff person? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why reference checks were not conducted:

7. Has the staff member been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, Provide the occurrence numbers, types, and dates:

Alleged Assailant - Family, Visitor or Other/Unknown

1. Describe:

Description

1. Describe what occurred:

2. Was the occurrence witnessed? (Yes/No)

   1. If yes, by whom?

3. Is financial exploitation of the consumer suspected?

   1. If yes:

      1. Is the consumer at risk of being discharged due to non-payment?

‘

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. When and where was the property last accounted for?

5. Has there been a pattern of misappropriation of property? (Yes/No)

   1. If yes, describe the pattern:

6. Was the alleged assailant interviewed by management? (Yes/No)

   1. If yes:

      1. Provide results of interview:

7. Provide a brief summary of the interviews conducted with other consumers and staff as relevant to the investigation:

8. Provide the results of documentation review:

9. Were policies and procedures followed? (Yes/No)

   1. If no:

      1. Describe deviation from policies and procedures:

10. Provide the conclusion of the internal investigation:

Facility Actions

1. Describe any changes made to the consumer's treatment regimen and/or care plan as a result of the occurrence:

2. Describe interventions that were put into place to help prevent a recurrence:

Notifications

1. Who was notified of the occurrence? (Police, physician, family/guardian, ombudsman, adult protective services, etc.)

Facility Name:

Occurrence ID:

Consumer Information

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence :

5. Provide physical status as relevant to this occurrence:

6. Does the consumer have a history of any of the following? (Select all that apply) Mental Illness, Intellectual/Developmental Disability, Substance Abuse, Dementia/Alzheimer’s Disease, Homelessness, Other:

7. Does the consumer have a history of elopement? (Yes/No)

   1. If yes: 

      1. Was there a safety plan in place? If so, describe:

8. Is the consumer responsible for self? (Yes/No)

9. Consumer’s status at the time of elopement (Voluntary, Involuntary M1-Hold, Involuntary Short-Term Certification, Involuntary Long-Term Certification, Other):

Description

1. Describe what occurred:

2. What was the consumer's location at the time of elopement (Unsecured Unit, secured unit, emergency department, community pass, other)?

3. What level of oversight was in place at the time of elopement (1:1, line of sight, frequent checks, other, none)?

4. What time was the consumer identified as missing?

5. When was the consumer last by staff?

6. Was the occurrence witnessed?

   1. If yes, by whom?

7. What was the consumer’s risk level at the time of elopement (At risk to self, at risk to others, not at risk)?

   1. If at risk to self or others, describe risk factors:

Investigation

1. Date investigation started:

2. Describe investigative actions taken:

3. How were consumers kept safe during the investigation:

4. Was a grounds search conducted?

5. Is the consumer’s whereabouts known at this time? (Yes/No)

   1. If yes, describe:

6. How long was the consumer missing?

7. Was the consumer assessed? (Yes/No)

   1. If yes:

      1. Who conducted the assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no

      1. Explain why the consumer was not assessed:

8. Was treatment provided to the consumer? (Yes/No)

   1. If yes

      1. Describe the treatment:

9. Was the consumer transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. What treatment was provided?

      3. Did the consumer return to the previous level of care?

10. Current status of consumer:

11. Provide the results of documentation review and interviews:

12. Were policies and procedures followed? (Yes/No)

    1. If no, describe any deviation and corrective action:

13. Provide the conclusion of the internal investigation:

Facility Actions

1. Describe any changes made to the consumer’s treatment regimen and/or care plan as a result of the occurrence:

2. Describe interventions that were put in place to help prevent a recurrence:

Notifications:

1. Who was notified of the occurrence? (Police, physician, family/guardian, etc.)

Facility Name:

Occurrence ID:

Consumer Information

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence :

5. Provide physical status as relevant to this occurrence:

Alleged Assailant - Staff Member or Other Service Provider

1. ID/Name of Staff Member:

2. Gender

3. Title

4. License/Certification Number:

5. Were background checks completed? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why background checks were not conducted:

6. Were reference checks completed on the staff person? (Yes/No)

   1. If yes, Describe any problems identified and the plan for supervision:

   2. If no, Explain why reference checks were not conducted:

7. Has the staff member been involved in any other occurrences in the past 12 months? (Yes/No)

   1. If yes, Provide the occurrence numbers, types, and dates:

Alleged Assailant - Family, Visitor or Other/Unknown

1. Describe:

Description

1. Describe what occurred:

2. Was the occurrence witnessed?

   1. If yes, who witnessed the occurrence? (Staff, Visitor, Consumer, Other)

   2. If consumer or staff, provide name/ID:

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. Was the consumer assessed? (Yes/No)

   1. If yes:

      1.  Who conducted an assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why the consumer was not assessed:

5. Was treatment provided to the consumer? (Yes/No)

   1. If yes:

      1. Describe the treatment:

6. Was the consumer transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. What treatment was provided?

      3. Did the consumer return to the previous level of care?

7. Current status of consumer:

8. Was the consumer interviewed? (Yes/No)

   1. If yes:

      1. Provide the results of the interview:

   2. If no:

      1. Why was the consumer not interviewed?

9. Describe any non-verbal responses and/or behavioral changes observed:

10. Was the alleged assailant interviewed by management? (Yes/No)

    1. If yes:

       1. Provide results of interview:

11.  Provide a brief summary of the interviews conducted with other consumers and staff as relevant to the investigation

12.  Provide the results of documentation review

13.  Were policies and procedures followed? (Yes/No)

    1. If no:

       1. Describe deviation from policies and procedures:

14.  Provide the conclusion of the internal investigation:

Facility Actions

1. Describe any changes made to the consumer's treatment regimen and/or care plan as a result of the occurrence.

2. If alleged assailant was a staff member or other service provider:

   1. In response to the conclusion of the investigation, what actions were taken with the alleged assailant?

3. Describe interventions that were put into place to help prevent a recurrence:

Notifications

1. Who was notified of the occurrence? 

   1. Other ( Police, family/guardian, physician, ombudsman, adult protective services, Board of Nursing, etc.):

Facility Name:

Occurrence ID:

Consumer Information

1. Name/ID:

2. Date of Birth:

3. Age at time of occurrence:

4. Provide cognitive status as relevant to this occurrence :

5. Provide physical status as relevant to this occurrence:

Description

1. Describe what occurred:

2. Was the occurrence witnessed?

   1. If yes, who witnessed the occurrence? (Staff, Visitor, Consumer, Other)

   2. If consumer or staff, provide name/ID:

Investigation

1. Date investigation started:

2. Describe the investigative actions taken:

3. How were the consumers kept safe during the investigation?

4. Was the consumer assessed? (Yes/No)

   1. If yes:

      1. Who conducted an assessment?

      2. When was the assessment conducted?

      3. Describe assessment findings:

   2. If no:

      1. Explain why the consumer was not assessed:

5. Was treatment provided to the consumer? (Yes/No)

   1. If yes:

      1. Describe the treatment:

6. Was the consumer transferred to a higher level of care? (Yes/No)

   1. If yes:

      1. Provide transfer details:

      2. What treatment was provided?

      3. Did the consumer return to the previous level of care?

7. Current status of consumer:

8.  Provide a brief summary of the interviews conducted with other consumers and  staff as relevant to the investigation:

9.  Provide the results of documentation review:

10.  Were policies and procedures followed? (Yes/No)

    1. If no:

       1. Describe deviation from policies and procedures:

11.  Provide the conclusion of the internal investigation:

Facility Actions

1. Describe any changes made to the consumer's treatment regimen and/or care plan as a result of the occurrence.

2. Describe interventions that were put into place to help prevent a recurrence:

Notifications

1. Who was notified of the occurrence? 

   1. Other ( Police, family/guardian, physician, ombudsman, adult protective services, Board of Nursing, Board of Medical Examiners, etc.):