Community Options Unit Acquired Brain Injury Critical Incident Report Form

Community Options Unit Acquired Brain Injury Critical Incident Report Form
Date*

MonthDayYear
Date
Agency: (example: HOTS)*
Staff Reporting Incident:*

First NameLast Name
Staff member present when Incident occurred:*
Location of the Incident:*
Individual/Consumer/Client Name:*

First NameLast Name
Medicaid ID:*
[Please note: Send completed form to the Care Manager]
CRITICAL INCIDENT TYPE*

Allegations of abuse, neglect, or exploitationof clientBug infestationClient aggressive behavior toward caregiverFallsFire in residence with significant risk toclientMedication errorsMissing person reported to policeMotor vehicle accidentCaregiver under the influence of alcohol/drugsRestraintRisk of eviction/HomelessnessSeclusionSelf-neglectSerious criminal allegation - client as perpetratorSerious criminal allegation - client as victimEmergency 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] *
Narrative describing what happened
Results of Investigation: 1. Who was involved 2. Witnesses 3. Persons Interviewed 4. What may have caused the incident *
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
Should be Empty:

Community Options Unit Acquired Brain Injury Critical Incident Report Form

[Please note: Send completed form to the Care Manager]

Description of Incident - Required