Incident INVESTIGATION Report

Incident Investigation Report

Investigators must attach copies of ALL documentation that was reviewed as part of their investigation and SCAN the original staff’s statements.
**Keep in mind CONFIDENTIALITY of others when interviewing. In the event an incident concerns more than one individual, one report may be written.
Incident Number (obtain this # from the RRDC if this investigation is in response to an Serious Reportable Incident):*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reporting Agency:*
Agency Contact: *

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Incident/ Complaint Date: *

YearMonthDay
Date
Definitions of Incidents*
InjuryNatural Death of a waiver participantSensitive SituationOther/ Serious Reportable Incidents
Abuse (Physical, Sexual, Psychological, Seclusion, Restraint, Mistreatment, Aversive conditioning)NeglectViolation of a participant's civil rightsMissing personDeath of a waiver participantUnplanned hospitalizationPossible criminal actionMedication error/refusal
Incident as Described on Incident Report Form or Complaint (This should read exactly as the description on the Incident Report Form.) *
Immediate Corrective Actions: (What actions were immediately taken to protect individual(s) and/or prevent future incident? For example, suspension of target(s), medical treatment for individual(s) involved, repair of environment, etc.)*
Additional Corrective Actions Taken: (Indicate what additional corrective actions were taken prior within timeframe of investigation (i.e., staff training, reimbursement to individual, etc.) *
ComplaintsService PlansProgress NotesBehavior PlansPlan of Protective OversightStaff schedulesStaff’s written statementsNotification ProcessOther
Persons Interviewed: (Include the name, title, date, time, location and whether or not you received a written statement. Interview Individual(s) involved If you did not receive a written statement, you must indicate the reason why. If you were unable to interview someone in person, you must indicate the reason why. For injuries of unknown origin, all persons who had contact with the individual from at least 24 hours prior to discovery of the injury MUST be interviewed. This includes all day program staff, transportation, etc. Keep in mind CONFIDENTIALITY at all times. Do NOT reveal to person being interviewed what another person interviewed stated. DO ask the target specifically at the end of your interview if in fact the incident occurred.)*
Background Information: (This is background information on the Individual. Include level of functioning, mode of communication, behavioral concerns, ability to report, credibility as a witness or ability to relate any of the events due to cognitive functioning. If unsure, consult with someone who knows the Individual well. If report directly involves more than one individual, include background information on each person.)*
Factual Findings/Summary of Evidence & Interviews: (Do not re-write witnesses’ statements verbatim. Just the summary of the facts provided. Think of this as a timeline of events. You can bullet events in the date and order they occurred according to statements and interviews. Include what all staff and/or Individuals have revealed in their statements. Do not repeat information already provided. If you have indicated what one person states and another person gives the same account of events, simply indicate that fact. State the facts of what documentation has revealed. Use direct quotes from interviews, if relevant. State the facts only as they are relevant to the incident you are investigating. Initially include full names and titles of staff and individuals. Once the full name and title are given, you may refer to them by first name throughout the rest of the report. Remember, your readers may not be not familiar with staff, Individuals, or the location of the event. Give as much specific information relevant to the incident as possible to make your summary clear and concise. )*
Un-reconcilable Inconsistencies: (After reviewing all the evidence/facts, what things contradict each other? (i.e., one staff may relay information about a participant and another staff interviewed may say something different. Include all such examples in this section. This also includes discrepancies between what someone told you during an interview vs. what they wrote in their statement.)*
Conclusion: (If investigating Allegation of Abuse/Neglect: Indicate only whether or not the incident/allegation is substantiated, inconclusive or disconfirmed. For example, “Investigators have deemed this as a substantiated incident of neglect”. Substantiated: The incident/allegation is found to be true. This occurs when someone admits to something, there are eyewitnesses to the incident or there is overwhelming evidence to support the allegation. Inconclusive: There is no way of knowing if the incident/allegation is true. This typically occurs when someone says one thing, someone says something else, and there are no eyewitnesses. Disconfirmed: There is proof the incident could not have happened or there is substantial amount of evidence or information to disconfirm. This occurs when a staff is accused of something on a day they were not working or there are eyewitnesses stating the allegation/incident did not take place, staff followed protocol correctly, etc. When investigating Serious Reportable or Recordable Incident: Indicate if incident/injury is known or unknown in cause and whether or not all appropriate actions were taken. (If you can make a justified determination as to cause of an injury even though it was not witnessed, you may indicate it was a “known” injury).*
Reasons to Support Conclusion: (Pull information form your report that supports your conclusion (i.e., eyewitness reports, behavior plan followed appropriately, probability of how injury occurred, etc. These can be listed with bullets.) *
Recommendations: (Recommendations must be numbered… 1, 2, etc. Recommendations are to be made relevant to the incident being investigated. Recommendations should include corrective and preventative measures and may be systemic in nature. These may be relevant to the environment, staffing, training, protection of other Individuals, revisions to service plans, or disciplinary action, Employee Assistance Program, mediation, re-assignment, or revision/development of an agency-wide policy, etc. Remember to empower the staff to carry out the recommendations by leaving the actual “how to” up to them. (For examples, where appropriate, broaden the recommendation to include a treatment team meeting to discuss possible revisions to a behavior plan. Recommendations for disciplinary action are to be made at the discretion of the agency administration, i.e., “Disciplinary action at the discretion of the Director of Waiver Services to (name of staff) for (reason) .”) *
Other issues/concerns not related to the outcome of this incident: (Sometimes other concerns or issues arise from an investigation that is not specifically relevant to the incident/complaint at hand. These separate issues may not necessarily be included in the actual report or recommendations, but may be sent in a separate memo to administration to make them aware of your concerns or under this separate heading within your report.)*
MUST attach copies of ALL documentation that was reviewed as part of the investigation and SCAN the original staff’s statements.

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The above recommendations were reviewed in conjunction with:
Name*

First NameLast Name
Title*
Date*

MonthDayYear
Date
Submitted by: (Name/Title of person completing investigation) *

First NameLast Name
Titled:*
Signature*

Clear
Date*

MonthDayYear
Date
1. Reviewed by:

First NameLast Name
Date

MonthDayYear
Date
2. Reviewed by:

First NameLast Name
Date

MonthDayYear
Date
3. Reviewed by:

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Incident Investigation Report