Date of Incident:

Time of Incident:

Location of Incident:

Description of Incident:

Resident(s) Involved:

Staff Member(s) Involved:

Witness(es) (if any):

Nature of Incident:

• Fall

• Medication Error

• Abuse/Neglect

• Wandering/Elopement

• Other (please specify)                              

Severity of Incident:

• Minor

• Moderate

• Severe

Immediate Response:

• First aid administered

• Emergency services called

• Notified family members

• Other (please specify)                              

Documentation:

• Incident report completed

• Medical records updated

• Witness statements obtained

• Other (please specify)                              

Follow-Up Actions:

• Care plan adjustment

• Staff retraining

• Further investigation

• Other (please specify)                              

Recommendations:

• Environmental modifications

• Staffing changes

• Policy/procedure updates

• Other (please specify)                              

Education and Training:

• Resident safety education

• Staff training on incident prevention

• Family education on risk factors

• Other (please specify)                              

Review Panel Members:

Findings:

Recommendations: