Incident Report Form With Instructions printable pdf download

INSTRUCTIONS FOR COMPLETING ESRD FACILITY INCIDENT REPORT FORM

TEXAS DEPARTMENT OF STATE HEALTH SERVICES (DSHS)

FACILITY LICENSING GROUP

Use this form to notify DSHS of an incident and the actions taken by the facility. Explain

how the facility will improve care as a result of the incident. Complete the entire form with

all requested attachments so that the DSHS may review the incident without requiring

additional information or documents.

Instructions for Completing the Incident Report Form

Print or type the information. Provide as much information as possible. Use the facility

name and license # on your license.

Reporting Information: Incident reports are required for the following:

1. death of a patient (Do not report death related to a traffic accident, pre-

scheduled elective surgery, hospitalization greater than 14 days, a do-not-

resuscitate (DNR) directive, a hospice patient, or a patient who withdraws

from dialysis);

2. any ambulance transport from the dialysis facility to a hospital due to the patient’s

emergent medical condition; this includes ambulance transports after a call to 911,

whether or not the lights are flashing and or the siren is on as the ambulance leaves

the dialysis facility or parking lot; do not report non-emergent transports.

3. conversion of staff or patient to hepatitis B surface antigen (HbsAg) positive (Submit

a report with lab results for all patients and staff in the facility, with their hepatitis

status, antibody status, and vaccination status);

4. involuntary transfer or involuntary discharge of a patient;

5. fire in the facility (submit the report from the fire department).

Facility Information: Include the facility license number, facility provider number (CCN),

address, contact person, telephone number, email address, and fax number. The facility

license number is on your facility license. The facility provider number is the Medicare six

digit number. The contact person will be the person the surveyor will ask for should a

follow-up telephone call be needed.

Summary: Briefly state what happened, who was involved (e.g., RN, LVN, PCT, MD,

other), and what action was taken at the time of the incident. For example: The treatment

was started without incident. About 2 Y, hours after the treatment began, the PCT noted

that the patient's blood pressure dropped from 130 systolic to 90 systolic. The nurse

assessed the patient and found the patient was asymptomatic. The blood pressure was

retaken, and it was 92 systolic. The patient was placed in Trendelenburg position, and the

blood pressure was retaken after 15 minutes. The patient began experiencing dizziness,

and the blood pressure was now 89 systolic. The nurse administered 200 cc normal saline.

After 15 minutes the blood pressure dropped to 80 systolic, and the physician was notified.

911 was called and the patient was transferred to the hospital for evaluation. She

remained there overnight and was discharged within 48 hours.

Incident Report Form With Instructions