New York State Department of Health Adult Care Facility INCIDENT REPORT DSS-3123 Rev. 05/12 Facility Name County Date of Incident Time Regulations 487. 7 d 1-13 488. 7 b 1-13 490. 7 d 1-11 Resident Name I. Reportable Incidents to the Department s Regional Office Resident s whereabouts were unknown for more than 24 hours Resident assaults or injures or is assaulted or injured by another resident staff or others Resident attempted or committed suicide if resident died must also check resident death below Complaint or evidence of resident abuse Resident Death A felony crime may have been committed by or against a resident Resident behaved in a manner that directly impaired the well-being care or safety of the resident or any other resident or which substantially interferes with the orderly operation of the facility Resident was involved in an accident on or off the facility grounds which resulted in such resident requiring medical care medical attention or services II. Non-Reportable Inci....
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How to fill out the NY DSS 3123 online
The NY DSS 3123 form is an important document used for reporting incidents in adult care facilities and assisted living environments. This guide will provide clear, step-by-step instructions to help you complete the form accurately and efficiently.
Follow the steps to complete the NY DSS 3123 online.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the facility name in the designated field to ensure the form is accurately representing the location of the incident.
- Fill in the county where the facility is located to maintain proper jurisdiction records.
- Specify the date of the incident by selecting from the date picker provided.
- Input the time of the incident in the given field, ensuring it reflects when the incident occurred.
- Refer to the regulations section and check the appropriate regulations that relate to the incident being reported.
- Enter the resident's name, and identify their level of care by circling all applicable options.
- Complete the section for reportable incidents, ensuring to check all relevant boxes based on the type of incident that occurred.
- Provide a detailed description of the incident, including any injuries or first aid given, as well as any employee involvement.
- Describe any immediate actions taken following the incident, including medical treatments administered.
- Detail any actions taken upon quality assurance review, ensuring to document systemic responses.
- Identify the individuals or agencies that provided care during or after the incident and specify the location of care provided.
- Summarize the current status of the resident(s) involved in the incident, including any ongoing concerns.
- Ensure the administrator or operator's signature is included, along with the date of signing.
- If applicable, include the resident's description of the incident, allowing for their comments or choice not to comment.
- Complete the reporting section, checking all relevant boxes and providing names and dates for those notified about the incident.
- Once all fields are completed, save your changes, download the document, print it for records, or share it as required.
Start completing your NY DSS 3123 online today to ensure accurate reporting of incidents.
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