Injury Investigation 

 

Resident Name: _____________________________________________________ 

 

Date of Incident: _______________________________ 

 

Time of Incident: _______________________________ 

 

Type of Injury (skin tear, bruise, etc.): _____________________________________ 

 

1.  Describe events: ________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

Witnessed: ¨ Yes ¨ No      If Yes, Name of Witness:  _________________________ 

 

2.  Resident’s Interview (Resident’s Statement):  _______________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

3.  Does resident have behaviors that may have contributed to injury (combativeness, restlessness, had a recent fall, etc.)? ¨ No ¨ Yes If yes, explain: 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

4.  Are there environmental factors that may have contributed to injury (consider arm/foot rests, siderails, etc. in proximity to injury)?  ¨ No ¨ Yes       If yes, explain: 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

5.  Does the resident have medical factors that may have contributed to injury (medical diagnosis or medication that may cause bleeding/bruising, etc.)?   ¨ No ¨ Yes    

If yes, explain: 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

6.  Staff Interview  - Indicate names of caregivers with statements as applicable  (Complete if unable to immediately determine cause of injury): 

 

______________________________________________________________________ 

 

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Signature:  _________________________________________________ 

 

Conclusion based on investigation: 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

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Care Plan intervention (preventative approach): 

 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

______________________________________________________________________ 

 

 

 

 

Resident Name: ______________________________________________ 

 

 

Intervention Date: ______________________________________________ 

 

 

Injury Investigation 

Standard 
All injuries occurring on the facility’s premises must be reported, documented, and investigated thoroughly to ensure the safety and well-being of residents, and compliance with CMS Requirements of Participation and the State Operations Manual (SOM) guidelines for long-term care facilities (LTC). 

Policy 
To ensure prompt and thorough investigation of any injury, identify contributing factors, and implement measures to prevent recurrence, maintaining a safe environment for residents. 

Practice Guidelines 

Injury Investigation Report Form 

Resident Name: _________________________________________________ 

Date of Incident: _______________________________ 

Time of Incident: _______________________________ 

Type of Injury (skin tear, bruise, etc.): _______________________________________ 

1. Describe Events: 
    
    
    
    

Witnessed: ☐ Yes ☐ No 
If Yes, Name of Witness: _________________________ 

2. Resident’s Interview (Resident’s Statement): 

 

 

 

3. Does resident have behaviors that may have contributed to injury (combativeness, restlessness, had a recent fall, etc.)? ☐ No ☐ Yes 
   If Yes, explain: 

 

 

4. Are there environmental factors that may have contributed to injury (consider arm/foot rests, side rails, etc. in proximity to injury)? ☐ No ☐ Yes 
   If Yes, explain: 

 

 

5. Does the resident have medical factors that may have contributed to injury (medical diagnosis or medication that may cause bleeding/bruising, etc.)? ☐ No ☐ Yes 
   If Yes, explain: 

 

 

6. Staff Interview - Indicate names of caregivers with statements as applicable (Complete if unable to immediately determine cause of injury): 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature: _________________________________________________ 

Conclusion based on investigation: 

 

 

 

 

 

 

 

 

Care Plan intervention (preventative approach): 

 

 

 

 

 

 

 

 

Resident Name: ______________________________________________ 

Intervention Date: ______________________________________________ 

Documentation and Investigation Action: 

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

• Use the specified Injury Investigation Report Form for documentation. 

• Witnesses, if any, must be documented on the report along with their contact information. 

• The Administrator and Director of Nursing Services (DNS) must be informed of all injuries and review completed reports. 

• If the incident is of a serious nature, it shall be reported by telephone regardless of the time or day. Follow the 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 the time of day, if the injury 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. 

• The Administrator is responsible for coordinating the investigation and assuring appropriate action is taken, including conducting interviews and collecting written statements from all staff involved. 

• Completed Injury Investigation Reports and Investigation forms must be submitted within 24 hours to the Administrator and DNS. 

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

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

References: 

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

• Requirements of Participation for Nursing Homes, CMS 

• Guidelines for Injury Investigation and Reporting, CMS