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Nursing home incident report template

A nursing home incident report built around what surveyors check. It covers resident and family notice, physician contact, protective steps and the five-working-day result. An abuse and unexplained-injury screen ties to the two-hour and 24-hour clocks. Use it for falls, elopements, skin injuries, fights between residents and other events.

Updated Oct 5, 20268 sectionsFree to print
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Before you start

When to use it

  • A resident has an accident, fall, injury, elopement, choking episode or other surprise event.
  • An injury is found and no one knows how. It may be an injury of unknown source.
  • A resident, family member or staff member alleges, or you suspect, abuse, neglect, exploitation, mistreatment or missing property.
  • A fight between residents, or a behavior event, puts a resident at risk.
  • A change in condition after an event needs physician and family notice, with times.

How to fill it out well

  1. If abuse or an unexplained injury is possible, start at section 2. Call the administrator first.
  2. Record clock times, not just dates. The 2-hour and 24-hour limits run from the moment of the allegation.
  3. Quote the resident's own words and note who was there. Report abuse allegations before judging if they are credible.
  4. Document every notice try, including unanswered calls, with the time.
  5. Write interim safety steps the same day. The care plan update should match what staff do.
  6. Keep witness statements, findings and corrective action together so the five-working-day report is easy to send.
  7. Give the completed report to the director of nursing or administrator by the end of the shift.

Nursing home incident report template

Organization: ______________________   Site: ______________________

1. Resident and event
Resident name, room and unit
Resident ID or medical record number
Date of event
Time of event
Time found, if differentKey for unwitnessed events.
Where it happenedResident roomBathroomHallwayDining roomTherapy areaOutdoors or courtyardTransport vehicleOther
Event typeFall or near-fallInjury of unknown sourceSkin tear or other injuryElopement or missing residentChoking or aspirationMedication eventResident-to-resident incidentAlleged abuse, neglect or mistreatmentMissing propertyEquipment or environmental hazardBehavior or self-harmOther
2. Abuse and reporting screen
Is there an allegation or suspicion of abuse, neglect, exploitation, mistreatment or theft of property?If yes, call the administrator now. Finish this form later. Federal rules (42 CFR 483.12(c)(1)) give 2 hours from the allegation for abuse or serious bodily injury, and 24 hours otherwise.YesNoUnsure: ask the administrator before continuing
Is this an injury of unknown source?All three: no one saw it, the resident cannot explain it, and it looks suspicious (size, place or number).Yes: all three criteria applyNoNot an injury
Serious bodily injury?CMS: extreme pain, major risk of death, long loss of function, or injury needing surgery, hospital care or rehab.YesNoUnknown
Date and time the allegation was made or the suspicion formedThis starts the reporting clock. Limits run on real clock time, not business hours.
Reported to administrator (name, date, time)
Reported to State Survey Agency, adult protective services or law enforcement (agency, date, time, confirmation number)A suspected crime has 2-hour and 24-hour limits too. State rules may be shorter.
Resident protected from further harm while the investigation is openSeparate the people involved, change assignments or add supervision (42 CFR 483.12(c)(3)).
3. What happened
Description of the eventWhat you saw, heard and did, in order. Quote the resident. No opinions.
Witnessed?WitnessedUnwitnessed: resident foundUnknown
Last time the resident was seen before the event, and by whomNeeded for any unwitnessed event.
Staff and others present or nearby
Resident's explanation, if anyUse their words. If they cannot explain, say why.
4. Resident condition and injury
Injuries found (location, size, color, description)Measure in cm. Note bruises, skin tears, swelling, deformity and pain on movement.
Injury levelNoneMinor: first aid onlyModerate: needs a doctor's exam or treatmentMajor: fracture, head injury or hospital transferDeath
Vital signs and pain score after the event
Mental status compared with usualA change may need immediate notice.Same as usualChanged: describe in the story
Treatment given
Transferred to hospital?NoYes: emergencyYes: scheduled evaluation
5. Notifications
Physician or nurse practitioner notified (name, date, time, orders received)You must consult the physician right away for an accident with injury that may need physician care (42 CFR 483.10(g)(14)).
Resident representative or family notified (name, relationship, date, time, by whom)The same rule covers the representative. Record every try if you cannot reach them.
Resident informed in terms they can understand
Director of nursing notified (date, time)
Medical director notified, if indicated (date, time)
Other state or local reports (state incident reporting, ombudsman)States set their own rules and deadlines. Check yours.
6. Immediate actions and care plan
Immediate actions taken
Interim safety measures started todaySay what changed now: supervision, device, room, toileting schedule, bed height.
Care plan updated
Risk assessment updated (fall, elopement, skin or behavior)
Staff briefed (shift, date)
7. Investigation
Investigation lead and start date
Findings: contributing conditionsList system conditions, not blame. Keep fact apart from opinion.
ConclusionViolation confirmedViolation not confirmedAccident: avoidableAccident: unavoidableStill under review
Date results reported to administrator and State Survey AgencyDue within 5 working days of the incident (42 CFR 483.12(c)(4)). If a violation is verified, corrective action is required.
Corrective action taken or planned (owner and due date)
Entered in the QAA/QAPI event log
8. Sign-off
Completed by (name and title)
Signature of person completing the report
Director of nursing or administrator review
Date reviewed
Editable copy

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We send an editable version you can adapt to your policies, plus a short checklist. No patient information, ever.

Tips

  • Report an allegation first, then investigate. CMS says do not judge if it is credible before reporting.
  • A fall without injury is still a fall. CMS counts a resident found on the floor as a fall unless evidence shows otherwise.
  • Review events by shift, location and time of day. The QAA committee needs to see patterns.
  • Use the fall incident report for extra fall detail: footwear, device, activity and the post-fall huddle.

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Questions

About this template.

Something we missed? Ask us, and a person answers.

How fast must a nursing home report suspected abuse?

Under 42 CFR 483.12(c)(1), report abuse, or an allegation with serious bodily injury, within 2 hours. Report neglect, exploitation or theft without serious bodily injury within 24 hours. Tell the administrator and State Survey Agency, plus others under state law. Results are due in 5 working days.

What is an injury of unknown source?

CMS uses the term when three things are true. No one saw how it happened. The resident could not explain it. And it looks suspicious by size, place (an area not usually hurt) or number. It is treated as an alleged violation, on the same clocks.

Who must be notified when a resident has an accident?

If an accident causes injury that may need a physician, act right away (42 CFR 483.10(g)(14)). Tell the resident, consult the physician and notify the resident representative. The same goes for a significant change in condition, a major treatment change, or a transfer or discharge decision.

Who has to report a suspected crime against a resident?

Covered individuals must report a reasonable suspicion of a crime against a resident to the State Agency and local police. They are the owner, operator, employee, manager, agent or contractor of a federally funded long-term care facility. The limit is 2 hours with serious bodily injury, 24 hours without. Facilities must tell them of this duty yearly.

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