Incident Report

Extended Life Home Care’s caregivers have the intentions of providing the best care possible. Unfortunately, instances arise, which makes providing care difficult, change the work relationship, or quite simply make everyone involved uncertain about the future. Extended Life Home Care understands such occurrences, and requires those instances be documented. Proper documentation enables ELHC to be informed, proceed with investigations (if needed), and provide resolution.

Please be as detailed as possible when reporting incidents. As a reminder, incidents should be reported within 24-48 hours of occurring.

Date * +

Date of Incident * +

Time of Incident *

Meridiem *

A.M.

P.M.

Issue Relation: *

Consumer Related Issue

Consumer Fall, Hospitalization, Injury or SCIC

Consumer Decision Affecting Services

Provider's FName *

Provider's LName *

Position *

Caregiver Email Address *

Caregiver Phone *

Consumer FName *

Consumer LName *

RN-Case Manager Over Case:

Identify the nature of the incident. *

Consumer Fall	Consumer Hospitalization
Consumer Injury	Change in physical, mental, emotional status
Consumer significant change in condition.	Medication and treatment error
Suspected Abuse, Neglect, or Exploitation	Unexpected death within twenty-four (24) hours of admission.

Identify the nature of the incident. *

Consumer not home for appointment.	Consumer declines/refuses services
Consumer refused to sign for services received	Consumer intends on changing services and/or agencies
Consumer address changes, extended stay, vacation	days, or hospitalization
Refusal of treatment.

Date of Scheduled Service * +

Reason for Refusal to Sign *

Did you instruct the caregiver to notify the agency? *

Yes

No

Did the consumer suffer from a fall? *

No

Yes

Consumer's status following fall: *

No obvious injury	Minor Injury
Major Injury	Unable to be determined/Uncertain

Did you recommend the consumer to visit the ER for evaluation? *

Yes

No

Did the consumer consult with their physcian or visit the ER? *

Yes

No

Admission Information

	Date	Time	Hospital Name	Admission Time
Specifics	Date	Time	Hospital Name	Admission Time

Was the consumer transported by EMS? *

Yes

No

Did you accompany the consumer? *

Yes

No

Type of abuse suspected or being reported *

PHYSICIAL ABUSE - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *

	W	R	S	U	N/A
Unexplained signs of injury such as bruises, welts, or scars, especially if they appear symmetrically on two side of the body	W	R	S	U	N/A
Broken bones, sprains, or dislocations	W	R	S	U	N/A
Report of drug overdose or apparent failure to take medication regularly (a prescription has more remaining than it should)	W	R	S	U	N/A
Broken eyeglasses or frames	W	R	S	U	N/A
Signs of being restrained, such as rope marks on wrists	W	R	S	U	N/A
Caregiver’s refusal to allow you to see the elder alone	W	R	S	U	N/A

EMOTIONAL ABUSE - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *

	W	R	S	U	N/A
In addition to the general signs above, indications of emotional elder abuse include:	W	R	S	U	N/A
Threatening, belittling, or controlling caregiver behavior that you witness	W	R	S	U	N/A
Behavior from the elder that mimics dementia, such as rocking, sucking, or mumbling to oneself	W	R	S	U	N/A
Other	W	R	S	U	N/A

SEXUAL ABUSE - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *

	W	R	S	U	N/A
Bruises around breasts or genitals	W	R	S	U	N/A
Unexplained venereal disease or genital infections	W	R	S	U	N/A
Unexplained vaginal or anal bleeding	W	R	S	U	N/A
Torn, stained, or bloody underclothing	W	R	S	U	N/A
Other	W	R	S	U	N/A

NEGLECT - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *

	W	R	S	U	N/A
Unusual weight loss, malnutrition, dehydration	W	R	S	U	N/A
Untreated physical problems, such as bed sores	W	R	S	U	N/A
Unsanitary living conditions: dirt, bugs, soiled bedding and clothes	W	R	S	U	N/A
Being left dirty or unbathed	W	R	S	U	N/A
Unsuitable clothing or covering for the weather	W	R	S	U	N/A
Unsafe living conditions (no heat or running water; faulty electrical wiring, other fire hazards)	W	R	S	U	N/A
Desertion of the elder at a public place	W	R	S	U	N/A
Other	W	R	S	U	N/A

FINANCIAL EXPLOITATION - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *

	W	R	S	U	N/A
Financial exploitation	W	R	S	U	N/A
Significant withdrawals from the elder’s accounts	W	R	S	U	N/A
Sudden changes in the elder’s financial condition	W	R	S	U	N/A
Items or cash missing from the senior’s household	W	R	S	U	N/A
Suspicious changes in wills, power of attorney, titles, and policies	W	R	S	U	N/A
Addition of names to the senior’s signature card	W	R	S	U	N/A
Unpaid bills or lack of medical care, although the elder has enough money to pay for them	W	R	S	U	N/A
Financial activity the senior couldn’t have done, such as an ATM withdrawal when the account holder is bedridden	W	R	S	U	N/A
Unnecessary services, goods, or subscriptions	W	R	S	U	N/A
Other	W	R	S	U	N/A

HEALTHCARE FRAUD AND ABUSE - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *

	W	R	S	U	N/A
Claiming and reporting work hours for services not performed.	W	R	S	U	N/A
Evidence of overmedication or undermedication	W	R	S	U	N/A
Failure for coordinating agency/provider to show.	W	R	S	U	N/A
Poorly trained staff, or insufficient staff; inadequate responses to questions about care	W	R	S	U	N/A
Other	W	R	S	U	N/A

Who is suspected of neglecting or abusing the person in question? *

Describe the type of abuse being reported. *

Environmental Changes Affecting Care *

Power Outage

Equipment Failure (Consumer's Equipment)

Usual Unpaid Caregiver Not Available to Service

Other

Briefly Describe Other *

Did you witness the reported incident (were you physically there)? *

Yes

No

Briefly describe the incident. *

I attest to the reported given. The information contained has been reported as accurate as possible, to the best of my ability. I understand that I must report this information promptly, and that failure to do so may adversely impact the consumer and potentially my employment.

Electronic Signature *

Environmental conditions affect the care of the consumer	Inappropriate behavior by a consumer
Consumer non-compliance	Conflicting Request
Consumer condition affecting health/welfare	Care is no longer needed
Hazardous waste spill	Health and safety issues affect services delivery
Medication and treatment error.	Suspected Abuse, Neglect, or Exploitation
Equipment/medical device failure or malfunction.	Equipment/medical device failure or malfunction.
staff incidents that require treatment, lost work days, or hospitalization	Solution or supply contamination
Staff member fails to report significant findings.	Missed Visit