Accident/Incident Reports 

Standard 

All accidents or incidents occurring on the facility’s premises must be reported. An incident is any occurrence not consistent with the routine operation of the facility, normal care of the resident, a happening involving visitors, malfunctioning equipment, or observation of a condition, which might become a safety hazard. 

Policy 

To provide a safe and healthful environment for residents, visitors, and employees. 

Practice Guidelines 

Reporting of Accidents/Incidents: 

• Regardless of how minor an accident or incident may be, it must be reported to the department supervisor and appropriate documentation completed on the shift that the accident or incident occurred. 

• Employees witnessing an accident or incident involving a resident, employee, or visitor must report such occurrence to their immediate supervisor immediately. Do not leave an accident victim unattended unless it is absolutely necessary to summon assistance. 

• Any unwitnessed accident or incident must be investigated for potential abuse, neglect, negligent treatment, misappropriation, or exploitation and reported according to policy and procedure for Reporting to Government Agencies. 

• The supervisor must be informed of all accidents or incidents to ensure the assessment of the resident and notification of physician/family is done. 

Assisting Accident/Incident Victims: 

• Should an employee witness an accident, or find it necessary to aid an accident victim, the employee should: 

Render immediate assistance. Do not move the victim until they have been examined for possible injuries. 

If it is a resident, move the resident to their bed once examined, if appropriate. 

If assistance is needed, summon help. If the employee cannot leave the victim, ask someone to report to the nurse's station that help is needed, or if possible, use the call system located in the resident’s room to summon help. 

If Medical Attention is Required, the Nurse Shall: 

• Examine all accident/incident victims. 

• Notify the attending physician of the accident or incident. 

• Notify the family as soon as possible concerning the accident/incident. 

• If the injury appears serious or questionable, the individual will be sent to the hospital by ambulance. Use 911 if necessary. 

• Any resident who sustains a blow to the head should be observed for neurological abnormalities. A neuro check will be initiated and done for 72 hours. If abnormal symptoms occur, the physician will be notified and the resident will be sent to the hospital. The family will then be notified. 

• First aid will be offered for minor cuts or abrasions after notification to the physician. 

Documentation and Investigation Action: 

• The charge nurse and/or the department director/supervisor must document the incident and conduct an immediate investigation of the accident or incident. 

• The specified Accident/Incident Form will be used for residents, employees, and visitors. 

• Witnesses, if any, will also be documented on the report. The address and telephone number of the witnesses will also be documented. 

• Every attempt will be made to ascertain the cause of the accident/incident. 

• The Administrator and Director of Nurses will be made aware of all such incidents occurring in the facility and will review completed reports. If any accident is of a serious nature, medically or suspected abuse, neglect, negligent treatment, misappropriation, or exploitation, it shall be reported by telephone regardless of time or day. Follow policy/procedure for Reporting to Government Agencies and Investigation of Abuse Practice Guidelines. 

• The Administrator must notify the Director of Clinical Services and Director of Operations immediately regardless of time of day if the Accident/Incident is of a serious nature. 

• The Administrator will ensure that staff directly involved will be suspended pending a complete investigation, depending on the circumstances of the incident (refer to policy/procedure for Abuse). 

• The Administrator is responsible for coordinating the investigation and assuring that appropriate action is taken, including but not limited to conducting interviews and collecting written statements from all staff or visitors involved in the situation. 

• Completed Accident/Incident Reports and Investigation forms must be submitted within 24 hours to the Administrator and the Director of Nurses. 

• Documentation in the Nurse's Notes is done timely. 

• The resident is monitored for 72 hours post any occurrence with Nurse's Notes every shift, including vital signs with documentation of any ill effects. 

Regulations on Reportable Events: 

• Class A: An event which has caused or resulted in a patient’s death or presents an immediate danger of death or serious harm. 

• Class B: An event that has caused, resulted in, or has the continuing potential to result in serious injury (including reportable diseases). An event that indicates an outbreak of disease or foodborne outbreaks. A complaint of patient abuse or an event that involves an abusive act to a patient by any person. For the purpose of this classification, abuse means a verbal, mental, sexual, or physical attack on a patient that may include the infliction of injury, unreasonable confinement, intimidation, or punishment. Also included are all witnessed, alleged, or suspected abuse, including all allegations of abuse without regard to whether the allegation is true. 

• Class C: An event (including but not limited to fire, loss of emergency electrical generator power, loss of heat, loss of water system) which has interrupted or has the potential to interrupt essential services provided by the facility. An event that will result in the evacuation of one (1) or more patients within or outside of the facility and all fires regardless of whether services are disrupted. 

• Class D: An event which has caused or resulted in a serious injury or a significant change in a patient’s condition; an event which involves medication error(s) of clinical significance; or an adverse drug reaction of clinical significance. For the purpose of this classification, clinical significance shall mean an event that adversely alters a patient’s mental or physical condition. 

• Class E: Classification of non-reportable events, an event which has caused or resulted in minor injury, distress, or discomfort to a patient. 

Only “Reportable Events” involving residents need to be reported. “Events” involving employees and visitors do not need to be reported to the Health Department, but do require an employee/visitor Accident/Incident report. 

Each report must be numbered as follows: the facility’s license number, the last two digits of the calendar year, and the sequential number of the report during the calendar year, e.g., #146-91-6. 

Subsequent reports relevant to any “Reportable Event” must be submitted “as often as is necessary” to inform the Department of significant changes in the status of affected individuals or changes in material facts originally reported. Subsequent reports must be attached to a copy of the original report. 

References: 

• Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

• Requirements of Participation for Nursing Homes, CMS 

• Guidelines for Investigating and Reporting Incidents, CMS