2. Did the Resident Die As a Consequence of the Accident?

Accident/Fall Reporting Flowsheet

1. Was the resident involved in the accident ambulatory[1] (without the aid of another) at the time of the fall/accident?

If NO, go to question 2.

If YES, did the facility or its employees have any culpability related to the fall (e.g. environmental hazards reasonably known or foreseeable - liquids on floor, equipment left in walking path, other examples).

If NO, STOP - there is not a requirement to report to the Department

If YES, go to question 2.

2. Did the resident die as a consequence of the accident?

If YES, report to the Department

If NO, go to question 3.

3. Was the resident admitted to the hospital or other higher level of care as a consequence of the accident?

(This does not include a resident sent to a hospital for diagnostic testing that does not result in admission.)

(If the resident is admitted for other reasons other than the accident, i.e. dehydration, there is no obligation to report.)

If YES, report to the Department.

If NO, go to question 4.

4. Did the accident result in (or was caused by) a spontaneous fracture?

If YES, STOP - there is not a requirement to report.

If NO, go to question 5.

5. Did the accident result in a hairline fracture?

If YES, STOP - there is not a requirement to report.

If NO, contact the treating physician, designee, physician extender to determine if the physician, designee or extender believes that the injury sustained by the resident is major.

If YES, report to the Department.

If NO, request the physician, designee, physician extender complete the INJURY NOTIFICATION FORM.

If the completed INJURY NOTIFICATION FORM is returned within 72 hours, STOP - retain the form in the clinical record, but do not report to the Department.

If the completed INJURY NOTIFICATION FORM is not returned within 72 hours, report the accident/fall to the Department.

If the completed INJURY NOTIFICATION FORM is received after a Report has been made to the Department, send the completed form to the Department, as a follow-up report.

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[1] Ambulatory means the condition of a person who immediately and without aid of another is physically capable of traveling a normal path to safety. The MDS section G and Care Plan will be reviewed by surveyors to confirm “ambulatory”.