Get Critical Incident Form

P. Date /Time DSP notified Law Enforcement Date /Time Day Program Type of Health Care Admissions and Date of Admissions check all that apply Psychiatric Hospital Date Acute Care Hospital Rehabilitation Facility Date Respite Center Emergency Room SS Developmental Center Date Nursing Home Hospice Reporter Name Relationship APS Child Child Protection Curator Direct Service Worker DSS EPS Friend/Neighbor Guardian Home Health Hospital HSS OAD OMH OPH Other Parent Provider Support Coordination Agency Agency Telephone Supervisor Sibling Spouse Under Curator HCBS Critical Incident Report Form Critical Incident Description Enter all information regarding the incident i.e. Who What When Where How et cetera. Name of Direct Service Provider Report completed by Date reported to SC Date Time Attach Supplemental Form to continue Each additional page must be signed and dated. Enter any follow-up related to the critical incident results of medical/dental appointments labs discharge instructions from hospital change in staffing medications treatments modifications to behavior support plan team meetings revision to ISP etc. Follow-up completed by Continue HCBS Critical Incident Report Form Note to Support Coordinator SC - If the SC discovers/witnesses an Abuse Neglect Exploitation or Extortion incident involving a participant between the ages of 18 -59 the SC should immediately verbally report the incident to APS. The SC should complete the CIR and keep a copy for his/her record. Department of Health and Hospitals Office for Citizens with Developmental Disabilities Home and Community Based Services HCBS Critical Incident Report Form PARTICIPANT IDENTIFYING INFORMATION Name First Name Middle if known Address City Region DOB Parish Gender Name Last State Telephone SSN Male Name of Family/Legal Guardian Female Telephone of Family/Guardian Family/Legal Guardian Address Service Type NOW CC SW ROW Funded Marital Status Single Married Divorced Separated Widowed Race African American White Hispanic Asian/Pacific Islander American Indian Alaskan Unknown/Other Disability Person having Autism Brain/Head Injury Cerebral Palsy Dementia Disease-Related Epilepsy Hearing Impairment Living Situation Mental Illness MR Mild MR Moderate MR Profound MR Severe Paraplegia Stroke Issued 09/18/09 Effective 10/01/09 Reissued 05-12-2010 Replaces July 22 2008 OCDDWSS-PF-08-001 Legal Status With Relatives Competent Major With Other/Unknown Interdicted Alone Emancipated With Roommate Minor With Spouse Continued Tutorship With Shared Supports In Licensed Facility In Unlicensed Facility Homeless Institutional Transition Yes No Speech Dysfunction Quadriplegia Substance Abuse Visual Impairment None Determinable Other Physical Other Developmental Disability Type Nursing Facility SSC DC ICF/DD Private OCDDWSS-PF-09-002 Page 1 of 6 Participant Name INCIDENT CATEGORIES Check only those that apply Note All protective services allegations must be verbally reported Child Abuse Primary Child Neglect Major Injury Major Illness Check if Sub Category applies Decubitis Seizure Pneumonia Bowel Obstruction Adult Abuse Neglect Exploitation Extortion Self Neglect Fall Major Behavioral Incident Attempted suicide Suicidal threats Self Endangerment Elopement/ missing Self injury Property Offensive Sexual Behavior Sexual Aggression Physical Aggression Elderly Death Major Medication Pharmacy Error Staff Error Family Error Participant Error Non Adherence Loss or Destruction of Home Involvement with Law Enforcement Staff arrested Staff issued a Citation for Moving Violation while participant is in vehicle Participant is a victim of a crime Restraints Use BEHAVIORAL Personal Mechanical Chemical MEDICAL EVENT INFORMATION Incident occurred Location of Incident Date /Time AM or PM Incident discovered Date /Time Home Community Facility DSP notified EPS Date /Time DSP notified C.