Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to access the KY Long Term Care Facility – Self-Reported Incident Form and open it in your preferred online editor.
2. Begin by filling out Part A, which requires you to enter the name and address of the facility, including street, city, state, and zip code. Be sure to provide accurate information.
3. In Part A, specify the incident date and location, along with the residents or clients involved and the staff implicated in the incident.
4. Next, you will need to list the required incident reports that apply to your situation by checking the appropriate boxes, such as fire, missing resident, or allegations of abuse.
5. Also in Part A, you can indicate any optional incident reports that may apply by checking those boxes as relevant.
6. Proceed to the notifications section and check all notifications that apply, including physician, family, local law enforcement, and others.
7. Move on to Part B to describe the incident. Include details of any injuries sustained and measures taken to protect the resident(s). Keep this description concise within the 500-character limit.
8. Continue in Part B by providing relevant resident history, such as cognitive status and fall risk assessment. This too should be under 500 characters.
9. If you are completing a 5-day follow up or final report, proceed to Part C to summarize the investigation, including actions taken, findings, and measures implemented to prevent recurrence, ensuring this is also limited to 500 characters.
10. Finally, complete the Reporting Party section by typing or printing your name, contact number, email address, and the date of reporting.
11. After all parts have been filled out, you can save your changes, download, print, or share the form as necessary.

Start completing the KY Long Term Care Facility – Self-Reported Incident Form online today to ensure timely reporting.