Kentucky Cabinet for Health and Family Services
Office of Inspector General – Division of Health Care
Long Term Care Facility – Self-Reported Incident Form
5 Day Follow up/Final Report
Combined Incident Report/Final Report
Please complete Parts A & B for 24-hour Initial notifications. Include Part C for 5 day Follow up/Final Reports.
Name of Facility ____________________________________________________
Incident Date _________________ Incident Location ____________________________________________
Resident(s)/Client(s) Involved _______________________________________________________________
Staff Involved ___________________________________________________________________________
Required Incident Reports
Optional Incident Reports
Notifications(Check all that apply)
Outbreak of Infectious Disease
Injuries of Unknown source
Resident’s Legal Representative
Allegations of Neglect
Utility Failure (more than 4 hours)
Allegations of Abuse/Mistreatment
Care and Treatment
Local Law enforcement
Incident Involving Life Safety Code
Appropriate Licensing Board
Death Other than by Natural Causes
Misappropriation of Property
Description of Incident. Please include injuries sustained as well as measures taken to protect the resident(s)
during investigation. Attach additional pages as necessary.
Please include relevant resident history (i.e. cognitive status, fall risk assessment, relevant care plan
instructions prior to this incident, etc.)
For 5-working day/final reports, please include a summary of the investigation (include investigative actions,
findings and causative factors) and corrective measure implemented to prevent recurrence.
Attach additional pages as necessary.
Failure to document credible protective/preventative measures at the time of initial reporting and/or
failure to provide evidence of a thorough investigation with corrective measures on the final report
may require an onsite visit to determine if acceptable measures are being take to protect residents.
Reporting Party (type or print clearly)
Reporting Party’s Contact Number
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