Incident Report Form

INCIDENT REPORT FORM

Please direct any questions to Steve Cazel at (360) 725–3706 or

Date Reported to the DBHR: / Date of Incident: / Time of Incident: (24 hour) / Location of incident:
Reporting Site:
RSNCHELAN/DOUGLASCLARK COGRAYS HARBORGREATER COLUMBIAKING CONORTH CENTRALNORTH SOUNDPENINSULAPIERCE/OPTUMSOUTH-WESTSPOKANETHURSTON/MASONTIMBERLANDS
Provider Agency: / Name of Reporter: / Phone/Email:
/
Brief description of the incident:
UNSUBSTANTIATED /
SUBSTANTIATED / UNDER INVESTIGATION/UNDETERMINED
POTENTIAL FOR MEDIA COVERAGE? / PROPERTY DAMAGE?
TYPE OF INCIDENT
Instructions: Please click on the appropriate category for drop down menu where indicated by an asterisk
*ALLEGATIONS / DEATHSAccidental OverdoseAlleged Abuse or Neglect of AdultAlleged Abuse or Neglect of ChildAlleged Abandonment of AdultAlleged Abandonment of ChildAlleged Financial Exploitation Involving PatientAlleged Financial Exploitation Involving Agncy/HosAlleged Financial Exploitation OtherAlleged Harassment of StaffAlleged Patient to Patient Sexual AssaultAlleged RapeAlleged Sexual AssaultAlleged Sexual Assault to StaffAlleged Staff to Patient Sexual AssaultDeath (Staff)Death (Visitor/Public)Death while in seclusion/RestraintDeath - NaturalDeath - SuicideDeath - HomicideDeath - AccidentDeath - OtherDeath - Unknown (at this time)Death - OTP
*INJURY / ESCAPESAssault of StaffEscape/UL by Mentally or Serious Violent Patient Escape/UL by Multiple PatientsEscape/UL OtherEscape/UL by Criminally Insane Patient Injury OtherMedication ErrorOtherPatient Injury Resulting from AccidentPatient Injury Resulting from Patient AssaultPatient Injury Resulting from FallPatient Injury Resulting from Self-InflictedPatient Injury Resulting from Restraint/InterventnPatient Injury Resulting from Staff AssaultPatient Injury Resulting from Staff Sexual AssaultPatient Injury Resulting from UnknownPatient Injury Resulting from OtherStaff Injury Resulting from AccidentStaff Injury Resulting from Patient AssaultStaff Injury Resulting from Restraint/InterventionStaff Injury Resulting from Other / *DISTURBANCE / CRIMEArrest/Crime - Charges of Homicide/Atmpt HomicideArrest/Crime - OtherArrest/Crime - Charges for Violnt Crm in Facility Bomb ThreatBreach of Client DataDisturbanceFireMedia InterestNatural DisasterProperty DamageTheft / Burglary - Loss of Patient DataViolent Act - ArsonViolent Act - Attempted HomicideViolent Act - HomicideViolent Act - Non fatal InjuryViolent Act - OtherViolent Act - Property Damage
PATIENT(1) INFORMATION / PATIENT(2) INFORMATION
Patient Identifier: / Name: Last, First / Patient Identifier: / Name: Last, First
PATIENT(3) INFORMATION / PATIENT(4) INFORMATION
Patient Identifier: / Name: Last, First / Patient Identifier: / Name: Last, First
STAFF (1) INFORMATION / STAFF (2) INFORMATION / STAFF (3) INFORMATION
Name: Last, First / Name: Last, First
/ Name: Last, First
VISITOR/OTHER INFORMATION
Name: Last, First / Relationship: / Other Pertinent Information Related to the Visitor:
OTHER AGENCY/FACILITIES NOTIFIED/INVOLVED
Law enforcement notified
Family notified
APS notified
CPS notified / DSHS Communications notified
Medicaid Control Fraud Unit
Department of Health
DSHS Notified / Media has contacted Agency
None
Other:
Date of referral:
FOLLOW-UP/CORRECTIVE ACTION INFORMATION / THIS INCIDENT DOES NOT REQUIRE FOLLOW-UP
Follow-up Date: / Action taken:
Follow-up Date: / Action taken:
Corrective Action Plan?
YES NO N/A / Describe CAP briefly:
Case closed?
YES NO / Date closed: / Incident Manager Comments:

DBHR Internal Form/IR_CatronC_8/2010

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