1. No category

Executive Office of Elder Affairs
Assisted Living Certification Unit
Contact
(617) 222-7461 - Fax: Incident Reports
(617) 222-7595 - Phone: Facility IR
(617) 222-7593 - Phone: Resident IR
alrincidentreport@state.ma.us
http://alrir.800ageinfo.com
Incident Report: Instructions
Version 1.0 (Feb 11, 2013)
Who should use Incident Report form 1.0?
·
ALRs who are participating in the ALR-Incident Reporting
Pilot.
·
All other ALRs please do not use. Continue making Incident
reports with existing materials.
Upcoming:
We expect to release an updated Incident Reporting
form, version 1.1, just as the ALR Pilots begin to use
QuickBase for automated Incident Reporting, after
Webinar 1 on Feb 20. Version 1.1 is expected to reflect
minor updates from the previous form.
Form 1.1 will be used by
· ALR Pilot users only if an Incident Report cannot
be reported using QuickBase
· all ALRs statewide, submitted via fax with a
notification voicemail.
Seven single-page variations
There are seven (7) separate IR paper forms – one for
each type of incident you are asked to report.
Choose the single-page IR paper form that best suits
the nature of the incident. Do not submit
multiple forms for any one incident.
The seven types of IR reports are as follows:
1.
Abuse, neglect or exploitation
2.
Acute health care emergency
3.
Adverse Medication Event
4.
Death
5.
Elopement
6.
Fall or Suspected Fall
7.
Facility-Wide emergency event
Although each IR paper form closely mirrors the
QuickBase IR reporting application, each Reporter is
required to make selections within each data field in
order for an IR to be submitted.
Each IR also includes a section for open-ended
Incident Narrative (please see templates, especially
Actions taken, if applicable). The Incident Narrative is
your opportunity to report about factors not
otherwise captured in the report form’s data fields.
This form is in a temporary format, expected to be used only by
ALR pilots for paper/ fax-based Incident Reporting between Feb
11 and Feb 25. See Upcoming at left.
How to use Incident Report Form 1.0
(1) Identify the Reportable Incident. Your Incident Report (IR) is
due within 24 hours of the incident or accident.
(2) Select the single-page report format that best matches the
Incident. There are seven (7) report variations, select one and
only one for the Incident.
(3) Write or Type on the Report page, filling in all fields. All
fields are required. Attach additional pages if necessary.
(4) Fax the IR page(s) to (617) 222-7461.
§
If unable to fax an Incident Report, then email a document
scan to alrincidentreport@state.ma.us. Make sure there is
no Personal Information (PI) or Protected Health Information
(PHI) in any emailed materials.
(5) Leave a brief notification voicemail. There are two different
numbers:
§
§
Resident-specific: (617) 222-7593
Facility-specific: (617) 222-7595
In choosing to select any item that appears in the drop down
menu associated with the type of incident you are reporting,
please try to choose the most accurate selection available
under the menu provided. If you believe your choice is only
by default and does not accurately represent the situation
you are reporting, explain this in the narrative.
S:\SIMS\Project Management\ALR Reports Project\Schema, New IR forms\ALR Incident Report forms - 7 variations - version 1.0 final.vsd
Executive Office of Elder Affairs
Assisted Living Certification Unit
Contact
(617) 222-7461 - Fax: Incident Reports
(617) 222-7595 - Phone: Facility IR
(617) 222-7593 - Phone: Resident IR
alrincidentreport@state.ma.us
http://alrir.800ageinfo.com
Incident Report: Abuse, Neglect, or Exploitation
Resident-specific
Version 1.0 (Feb 11, 2013)
There are seven (7) separate IR forms – one for each type of Incident.
Select the single-page IR paper form that best suits the nature of
the Incident. Do not submit multiple forms for any one Incident.
ALR
name
Town
Incident Information
Incident
Date/ Time
Reporter’s
Name
Reporter’s
Phone
Headline
Resident Type
q SCR
Eight (8) words or less
Nature of the Incident
q Traditional AL
Abuse, Neglect, or Exploitation
Specific Type
q GAFC
Detail Type
Reported
by
Select one (1) only below that best matches the Incident
Resident Status
Select one (1) only below
Select one (1) only below
q
Emotional abuse -- includes assault
without physical injury
q
Allegation by Mandated
Reporter
q
Admitted -- Resident admitted to
hospital
q
Exploitation -- includes financial
abuse, identity or property theft
q
Allegation by Resident
q
q
q
Allegation by Family
Evaluation -- Resident to ER or
Physician for evaluation
Physical abuse - includes assault with
injury
q
q
Recovering -- Resident
recovering at residence
q
Allegation by Another
(specify in narrative)
Sexual abuse
q
No Recovery necessary
Incident Narrative (including Actions taken)
If none, then note “None”.
Outside
Parties
(Check all that apply)
q
q
EMT
Family
q
q
MD
Other Health Care Provider
(specify in Narrative)
q
q
Police
Other Party
(specify in Narrative)
S:\SIMS\Project Management\ALR Reports Project\Schema, New IR forms\ALR Incident Report forms - 7 variations - version 1.0 final.vsd
q
None
Executive Office of Elder Affairs
Assisted Living Certification Unit
Contact
(617) 222-7461 - Fax: Incident Reports
(617) 222-7595 - Phone: Facility IR
(617) 222-7593 - Phone: Resident IR
alrincidentreport@state.ma.us
http://alrir.800ageinfo.com
Incident Report: Acute Healthcare Emergency
Resident-specific
Version 1.0 (Feb 11, 2013)
There are seven (7) separate IR forms – one for each type of Incident.
Select the single-page IR paper form that best suits the nature of
the Incident. Do not submit multiple forms for any one Incident.
ALR
name
Town
Incident Information
Incident
Date/ Time
Reporter’s
Name
Reporter’s
Phone
Headline
Resident Type
q SCR
Eight (8) words or less
Nature of the Incident
q Traditional AL
Acute Healthcare Emergency
Specific Type
q GAFC
Detail Type
Select one (1) only below that best matches the Incident
q
Emotional Symptoms - Exhibits or
complains of serious emotional
symptoms
q
Physical Symptoms - Exhibits or
complains of serious physical
symptoms
q
Threatens Immediate Harm Threatens immediate harm to self or
other(s)
Resident Status
Select one (1) only below
Select one (1) only below
q
Known - Source of the injury
is clearly identified
q
Requires urgent medical care for
physical injury
q
Not Confirmed - cause of the
disturbance or injury is
suspected but not confirmed
q
Requires the urgent intervention
by other health or safety
personnel
q
Unknown - source of
disturbance or injury is
unknown
q
Other (explain in narrative)
Incident Narrative (including Actions taken)
If none, then note “None”.
Outside
Parties
(Check all that apply)
q
q
EMT
Family
q
q
MD
Other Health Care Provider
(specify in Narrative)
q
q
Police
Other Party
(specify in Narrative)
S:\SIMS\Project Management\ALR Reports Project\Schema, New IR forms\ALR Incident Report forms - 7 variations - version 1.0 final.vsd
q
None
Executive Office of Elder Affairs
Assisted Living Certification Unit
Contact
(617) 222-7461 - Fax: Incident Reports
(617) 222-7595 - Phone: Facility IR
(617) 222-7593 - Phone: Resident IR
alrincidentreport@state.ma.us
http://alrir.800ageinfo.com
Incident Report: Adverse Medication Event
Resident-specific
Version 1.0 (Feb 11, 2013)
There are seven (7) separate IR forms – one for each type of Incident.
Select the single-page IR paper form that best suits the nature of
the Incident. Do not submit multiple forms for any one Incident.
ALR
name
Town
Incident Information
Incident
Date/ Time
Reporter’s
Name
Reporter’s
Phone
Headline
Resident Type
q SCR
Eight (8) words or less
Nature of the Incident
q Traditional AL
Adverse Medication Event
Specific Type
q GAFC
Detail
Detail
TypeType
Resident
Resident
Status
Status
Select
Select
one (1)
oneonly
(1) only
below
below
Select
Selectone
one(1)
(1)only
onlybelow
belowthat
thatbest
bestmatches
matches the Incident
q
SelectSelect
one (1)
one
only
(1)below
only below
Compromise likely - Rx
administration was likely
compromised
q
LMA - Resident was receiving LMA
q
Confirmed - injury has resulted
q
q
Negative - no injury is evident
q
SAMM - Resident was receiving
SAMM
Unknown - unknown if Rx
administration was compromised
q
q
Possible - injury may result
q
Both - Resident was receiving both
LMA & SAMM
Diversion Suspected - Diversion of
Rx med is suspected (explain in
narrative)
q
Neither - Resident was not
receiving either LMA or SAMM
Incident Narrative (including Actions taken)
If none, then note “None”.
Outside
Parties
(Check all that apply)
q
q
EMT
Family
q
q
MD
Other Health Care Provider
(specify in Narrative)
q
q
Police
Other Party
(specify in Narrative)
S:\SIMS\Project Management\ALR Reports Project\Schema, New IR forms\ALR Incident Report forms - 7 variations - version 1.0 final.vsd
q
None
Executive Office of Elder Affairs
Assisted Living Certification Unit
Contact
(617) 222-7461 - Fax: Incident Reports
(617) 222-7595 - Phone: Facility IR
(617) 222-7593 - Phone: Resident IR
alrincidentreport@state.ma.us
http://alrir.800ageinfo.com
Incident Report: Death
Resident-specific
Version 1.0 (Feb 11, 2013)
There are seven (7) separate IR forms – one for each type of Incident.
Select the single-page IR paper form that best suits the nature of
the Incident. Do not submit multiple forms for any one Incident.
ALR
name
Town
Incident Information
Incident
Date/ Time
Reporter’s
Name
Reporter’s
Phone
Headline
Resident Type
q SCR
Eight (8) words or less
Nature of the Incident
q Traditional AL
Death
q GAFC
Specific Type
Detail Type
Select one (1) only below that best matches the Incident
Resident Status
Select one (1) only below
Select one (1) only below
q Death was not anticipated
q Was Hospice patient
q Suspected suicide
q Was not hospice patient
q Deceased
q Other (explain in narrative)
Incident Narrative (including Actions taken)
If none, then note “None”.
Outside
Parties
(Check all that apply)
q
q
EMT
Family
q
q
MD
Other Health Care Provider
(specify in Narrative)
q
q
Police
Other Party
(specify in Narrative)
S:\SIMS\Project Management\ALR Reports Project\Schema, New IR forms\ALR Incident Report forms - 7 variations - version 1.0 final.vsd
q
None
Executive Office of Elder Affairs
Assisted Living Certification Unit
Contact
(617) 222-7461 - Fax: Incident Reports
(617) 222-7595 - Phone: Facility IR
(617) 222-7593 - Phone: Resident IR
alrincidentreport@state.ma.us
http://alrir.800ageinfo.com
Incident Report: Elopement
Resident-specific
Version 1.0 (Feb 11, 2013)
There are seven (7) separate IR forms – one for each type of Incident.
Select the single-page IR paper form that best suits the nature of
the Incident. Do not submit multiple forms for any one Incident.
ALR
name
Town
Incident Information
Incident
Date/ Time
Reporter’s
Name
Reporter’s
Phone
Headline
Resident Type
q SCR
Eight (8) words or less
Nature of the Incident
q Traditional AL
Elopement
q GAFC
Specific Type
Detail Type
Detail Type
Resident Status
Resident Status
Select one
Select
(1) only
one (1)
below
only below
Select
Selectone
one(1)
(1)only
onlybelow
belowthat
thatbest
bestmatches
matches the Incident
Select one (1) only
Select
below
one (1) only below
q
Traditional ALR resident
q
Was known to be at-risk
q
q
Resident of SCR
q
Was NOT known to be
at-risk
Located - Uninjured -- Resident is found/
returned and not injured
q
Located - Injured -- Resident is located, and
injury is suspected or confirmed
q
Located - health unknown -- Resident's
location confirmed; health status unknown
q
Whereabouts unknown - Resident has not
been located
q
Other (describe in narrative)
Incident Narrative (including Actions taken)
If none, then note “None”.
Outside
Parties
(Check all that apply)
q
q
EMT
Family
q
q
MD
Other Health Care Provider
(specify in Narrative)
q
q
Police
Other Party
(specify in Narrative)
S:\SIMS\Project Management\ALR Reports Project\Schema, New IR forms\ALR Incident Report forms - 7 variations - version 1.0 final.vsd
q
None
Executive Office of Elder Affairs
Assisted Living Certification Unit
Contact
(617) 222-7461 - Fax: Incident Reports
(617) 222-7595 - Phone: Facility IR
(617) 222-7593 - Phone: Resident IR
alrincidentreport@state.ma.us
http://alrir.800ageinfo.com
Incident Report: Fall or Suspected Fall
Resident-specific
Version 1.0 (Feb 11, 2013)
There are seven (7) separate IR forms – one for each type of Incident.
Select the single-page IR paper form that best suits the nature of
the Incident. Do not submit multiple forms for any one Incident.
ALR
name
Town
Incident Information
Incident
Date/ Time
Reporter’s
Name
Reporter’s
Phone
Headline
Resident Type
q SCR
Eight (8) words or less
Nature of the Incident
q Traditional AL
Fall or Suspected Fall
Specific Type
q GAFC
Detail Type
Detail Type
Resident
Resident
Status
Status
Select one
Select
(1) only
one (1)
below
only below
Select
Selectone
one(1)
(1)only
onlybelow
belowthat
thatbest
bestmatches
matches the Incident
q
Witnessed fall
q
Un-witnessed fall
Select
Select
one
one
(1)(1)
only
only
below
below
q
Evaluation - Resident to ER or Physician
for evaluation
q
Admitted -- Resident
admitted to hospital
q
Confirmed injury - staff confirms injury
q
q
Symptoms - Resident exhibits or
complains of related symptoms
Evaluation -- Resident to ER
or Physician for evaluation
q
NONE - Resident asserts no injury, and
none suspected
Recovering -- Resident
recovering at residence
q
No Recovery necessary
q
Incident Narrative (including Actions taken)
If none, then note “None”.
Outside
Parties
(Check all that apply)
q
q
EMT
Family
q
q
MD
Other Health Care Provider
(specify in Narrative)
q
q
Police
Other Party
(specify in Narrative)
S:\SIMS\Project Management\ALR Reports Project\Schema, New IR forms\ALR Incident Report forms - 7 variations - version 1.0 final.vsd
q
None
Executive Office of Elder Affairs
Incident Report: Facility-wide
Assisted Living Certification Unit
Contact
(617) 222-7461 - Fax: Incident Reports
(617) 222-7595 - Phone: Facility IR
(617) 222-7593 - Phone: Resident IR
alrincidentreport@state.ma.us
http://alrir.800ageinfo.com
Version 1.0 (Feb 11, 2013)
There are seven (7) separate IR forms – one for each type of Incident.
Select the single-page IR paper form that best suits the nature of
the Incident. Do not submit multiple forms for any one Incident.
ALR
name
Town
Incident Information
Incident
Date/ Time
Reporter’s
Name
Reporter’s
Phone
Headline
Eight (8) words or less
Nature of the Incident
Facility-wide
Name of Units
Facility-wide Incident
Residents
Units
(select number affected)
(select number affected)
q
q
q
q
q
q
q
q
25 or fewer
26 - 50
51 - 75
76 or more
Location
25 or fewer
q
Traditional AL
26 - 50
q
SCR
51 - 75
q
AL & SCR
76 or more
Duration of
Displacement
q 24 to 36 hours
q
q
q
36 to 72 hours
3 to 4 days
5 days or more
Arrangement
q
q
q
Return to family
q
Other (specify in narrative)
Remaining onsite at ALR
Transferred to licensed
health facility
Incident Narrative, including Actions taken, if applicable
If none, then note “None”.
Outside
Parties
(Check all that apply)
q
Local Fire
Department
q
Local Board
of Health
q
Other State Authority
(specify in Narrative)
S:\SIMS\Project Management\ALR Reports Project\Schema, New IR forms\ALR Incident Report forms - 7 variations - version 1.0 final.vsd
q
Other Party
(specify in Narrative)
q
None