Community Options Unit Acquired Brain Injury Critical Incident Report Form
Date
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Month
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Day
Year
Date
Agency: (example: HOTS)
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Staff Reporting Incident:
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First Name
Last Name
Staff member present when Incident occurred:
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Location of the Incident:
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Individual/Consumer/Client Name:
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First Name
Last Name
Medicaid ID:
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[Please note: Send completed form to the Care Manager]
CRITICAL INCIDENT TYPE
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Allegations of abuse, neglect, or exploitationof client
Bug infestation
Client aggressive behavior toward caregiver
Falls
Fire in residence with significant risk toclient
Medication errors
Missing person reported to police
Motor vehicle accident
Caregiver under the influence of alcohol/drugs
Restraint
Risk of eviction/Homelessness
Seclusion
Self-neglect
Serious criminal allegation - client as perpetrator
Serious criminal allegation - client as victim
Emergency Room/Unplanned Hospitalization
Description of Incident - Required
Description of Incident: WHO- [was involved] WHAT-[happened] WHERE-[did it happen] WHEN-[did it happen] WHY-[did it happen]
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Narrative describing what happened
Results of Investigation: 1. Who was involved 2. Witnesses 3. Persons Interviewed 4. What may have caused the incident
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WHERE-[did he get follow up, doctor, ER] WHO-[else was involved? Police, get office name and town? Family called, COP called?] URGENT/HIGH LEVEL-needs to be informed to CM immediately-Abuse, Assault, Criminal activity, Death, Fire, Neglect Police involvement, Wandering, anything that threatens the Safety of a client.
If investigation indicates this was a preventable incident due to caregiver issue, a corrective action plan is required: - Area identified for improvement -Training needs -Change in policy/procedure - How to prevent future occurrence -Who is going to implement changes and follow up
THIS SECTION IS ONLY FOR MANAGMENT
Submit
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