Get NJ AAS-45 2014-2024

New Jersey Department of Health Division of Health Facility Survey and Field Operations Long Term Care Assessment and Survey Program / Complaint Unit P. O. Box 367 Trenton NJ 08625-0367 Hotline 1-800-792-9770 Select 1 Fax 609-633-9060 or 609-943-4977 REPORTABLE EVENT RECORD / REPORT Please answer all questions fully and address only one event per report. New Jersey Department of Health Division of Health Facility Survey and Field Operations Long Term Care Assessment and Survey Program / Complaint Unit P. O. Box 367 Trenton NJ 08625-0367 Hotline 1-800-792-9770 Select 1 Fax 609-633-9060 or 609-943-4977 REPORTABLE EVENT RECORD / REPORT Please answer all questions fully and address only one event per report. Today s Date MM/DD/YY Was This a Significant Event Yes Date of Event MM/DD/YY Was Significant Event Called In No Time of Event Date MM/DD/YY AM PM Time Full Name of Facility Street Address City Facility Telephone Number State Facility License Number Person Reporting Zip Code Provider ID Number Title Type of Facility Assisted Living or Comprehensive Personal Care Home Adult/Pediatric Day Health Services ICF/IID Nursing Home Residential Sub-Acute Care Other Specify Exact Location of Incident AAS-45 SEP 14 Page 1 of 3 Pages. Continued Type of Incident Elopement Environmental Emergency Financial Exploitation Injury Interruption of Service Involuntary Discharge Involuntary Relocation Medication Error Resident Care Resident-to-Resident Abuse Staff-to-Resident Abuse Unexpected Death Unit and Room Number Date of Birth Narrative 1 Describe the event to include timeframes/risk factors related to the incident/event relevant resident Dx 2 Prior to the event was a plan of care developed that addressed this issue and were planned interventions in place when the event occurred For example chair alarm and/or lap buddy in place. If Yes please describe 3 What interventions were implemented after the incident/event For example supervision resident sent to hospital CNA suspended* Please describe investigative findings/conclusions Nurse Aide Involvement If the event is an allegation of abuse neglect or misappropriation of resident funds by a nurse aide please provide the certification number and certificate expiration date. For a nurse aide with no certification please provide the Social Security Number. Name Certification Number Expiration Date Notifications MD Specify OOIE Ombudsman Specify Date FOR NJDOH USE ONLY Reviewed By Surveyor ID Number and Initials Other Review ID Number and Initials Disposition Pending No Action Complaint Investigation Referral Specify Closed Specify Date Closed Comments. O. Box 367 Trenton NJ 08625-0367 Hotline 1-800-792-9770 Select 1 Fax 609-633-9060 or 609-943-4977 REPORTABLE EVENT RECORD / REPORT Please answer all questions fully and address only one event per report. Today s Date MM/DD/YY Was This a Significant Event Yes Date of Event MM/DD/YY Was Significant Event Called In No Time of Event Date MM/DD/YY AM PM Time Full Name of Facility Street Address City Facility Telephone Number State Facility License Number Person Reporting Zip Code Provider ID Number Title Type of Facility Assisted Living or Comprehensive Personal Care Home Adult/Pediatric Day Health Services ICF/IID Nursing Home Residential Sub-Acute Care Other Specify Exact Location of Incident AAS-45 SEP 14 Page 1 of 3 Pages. .