Long Term Care Facility - Self-Reported Incident Form
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1Kentucky Cabinet for Health and Family Services
Office of Inspector General – Division of Health Care
Long Term Care Facility – Self-Reported Incident Form
Initial Report
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.
Part A
Name of Facility ____________________________________________________
Address ________________________________________________________________________________
Street
City
State
Zip
Incident Date _________________ Incident Location ____________________________________________
Resident(s)/Client(s) Involved _______________________________________________________________
Staff Involved ___________________________________________________________________________
Required Incident Reports
Optional Incident Reports
Notifications(Check all that apply)
Fire
Communicable Disease
Physician
Missing Resident/Elopement
Outbreak of Infectious Disease
Family/Guardian
Injuries of Unknown source
Storm Damage
Resident’s Legal Representative
Allegations of Neglect
Utility Failure (more than 4 hours)
DCBS
Allegations of Abuse/Mistreatment
Care and Treatment
Local Law enforcement
Physical Abuse
Incident Involving Life Safety Code
Appropriate Licensing Board
Sexual Abuse
Death Other than by Natural Causes
Attorney General
Mental Abuse
Other _______________________
Ombudsman
Verbal Abuse
Other ____________________
Seclusion
Misappropriation of Property
Part B
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.)
Part C
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)
Date
Reporting Party’s Contact Number
Page ___ of ___
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