EXAMPLE

TRI-COUNTIES REGIONAL CENTER VENDOR INCIDENT REPORT

STEPS FOR PROVIDER SPECIAL INCIDENT REPORTING:
1. Verbally notify SIR Specialist of all special incidents within 24 hours to Vta. Co. (805) 351-3135 SB/SLO Co.(805) 539-2515
2. Submit written report to TCRC within 48 hours via SIR fax# to Vta. Co. (805) 456-0870
SB/SLO Co. (805) 456-2197
3. Notify applicable agencies (CCL, APS, CPS/CWS, DHS, Ombudsman, Law Enforcement) per regulations.
4. Notify Responsible person, (i.e., parent, guardian, conservator) per requirements.
Name of Individual: Sam Borchard
UCI#:660000
Sex: X M F
Date of Birth:06/01/1975
Date of Report: 11/1/2006_____ Check Applicable Boxes: X Verbal Non-Verbal XAmbulatory Non Ambulatory
Conserved
Additional incident types required for FHAs per Title
Required by Title 17, 54327
17, 56093

Death of an Individual (regardless of cause or location)

Individual is missing; vendor notified law enforcement
Individual was the victim of a crime (regardless of location)
Reasonably suspected abuse/exploitation:
Physical
Psychological
Fiduciary
Sexual
Physical Restraint
Chemical Restraint
Reasonably suspected neglect:
Failure to provide medical care
Failure to prevent malnutrition or dehydration
Failure to provide care
Failure to protect from health and safety hazard
Failure to assist with personal hygiene or the
provision of food, clothing or shelter
Unplanned or unscheduled hospitalization due to:
Cardiac-related
Respiratory Illness
Diabetes-Related
Seizure-Related
Internal Infection
Wound/Skin Care
Nutritional Deficiencies
Other
Involuntary Psychiatric Admission
Serious injury or accident, including:
Dislocation
Fracture
Laceration requiring sutures/staples
Burns, bites, puncture wounds or internal bleeding
Medication reaction requiring treatment beyond first aid
X ANY medication error (see below)
Medication Involved
Prescribing Physician
Dr.
Michael Kind
Clonazepam

Agency/Individual
Number:

Contact Name:

Any occurrence/allegation of abuse toward the individual

Incident which may result in criminal charges or legal action
Incident which may result in denial of individuals right(s)
Poisoning
Catastrophe
Emergency treatment Fire or explosion
Any other event which appears to have a significant negative
effect on the individuals health, safety, or wellbeing
OTHER INCIDENTS
Aggressive act to self Aggressive act to staff
Aggressive act to peer Aggressive act to family or visitor
Aggressive act to community member
Arrest
Law enforcement contact
Community safety
Diagnosis of communicable disease/parasite
Emergency Room visit
Injury:
From a seizure From a behavior episode From a peer
Accident
Unknown origin
Property damage
Suicide episode:
Threat
Attempt
Theft by Individual served by TCRC
Other unplanned hospitalization
Voluntary psychiatric hospitalization
Alleged violation of individuals rights
Other sexual incident:
Sexual harassment Unexplained pregnancy
Inappropriate contact
Verbal threats and aggression
Unauthorized absence
Use of restrictive behavior intervention
Health and safety issue
Other

OTHER AGENCIES/INDIVIDUALS NOTIFIED:

Contact Date:
Telephone:

Tri-Counties Regional Center:

______Manny Owens_______

11/01/2006_____

__(805) 962-7881_

Community Care Licensing:

______Fred Factor__________

11/01/2006____

__(805) 555-2242

Report
___________________
___________________

Licensing & Certification (DHS): _________________________

______________

_______________

___________________

Parent/Guardian/Conservator:

_________________________

______________

_______________

___________________

Physician/Hospital:

_________________________

______________

_______________

___________________

Child/Adult Protective Services: _________________________

______________

_______________

___________________

Long Term Care Ombudsman: _________________________

______________

_______________

___________________

Law Enforcement:

_________________________

______________

_______________

___________________

County Coroner:

_________________________

______________

_______________

___________________

Other:

______Dr. Michael Kind______

11/01/2006_____

__(805) 555-2190_

COMPLETE FRONT/BACK CONFIDENTIAL CLIENT INFORMATION W&I CODE, SECTION 4514

EXAMPLE
Date of Incident:__11/1/2006 Time of Incident:_ 07:30 a.m._______ Location of Incident:_ACME Home#2____
DESCRIPTION OF INCIDENT (Title 17 requires a description of the alleged perpetrator, if applicable):

Per Bob Smith, Administrator at ACME Home #2, while reviewing Sams medication and records, it was noted that his
Clonazepam order was documented incorrectly on the medication records and medication administration times on the
bubblepacks were incorrect resulting in incorrect administration for the month of October. The order should have been
given and documented as Clonazepam .5mg, 1 tab at 8am and Clonazepam 1 mg, 1 tab at 8pm. Instead it was given as
Clonazepam 1mg, 1 tab at 8am and Clonazepam . 5mg, 1 tab at 8pm.
(Attach a separate page for additional information)
IMMEDIATE ACTION TAKEN BY SERVICE PROVIDER/VENDOR /OTHER:

Dr. Kind's office was called to confirm the correct Clonazepam order. The Pharmacy was notified of their packing and
documentation error. Dr. Kind requested that the correct dosage of Clonazepam be given: .5mg 1 tab am and 1mg 1 tab
pm. Side effects reviewed with Dr. Kind. Sam has exhibited increased drowsiness in the mornings throughout this
month. Dr. Kind reported that the decrease in doseage should eliminate this problem. If not, we are to contact him ASAP.
(Attach a separate page for additional information)
MEDICAL TREATMENT NECESSARY: Yes X No If yes, describe the nature of the treatment:
Administered At:______________________________________ Administered By:______________________________________
Follow-up Treatment, if any:

PLAN TO PREVENT FURTHER OCCURRENCES:

A re-training and review of proper medication administration procedures was conducted by home administrator (Bob
Smith) with Sally Franklin, manager of ACME Home #2. Bob and Sally reviewed the training on medications and
administering medications when there is a "change" to the original prescription

(Attach a separate page for additional information)

COMMENTS (INCLUDE THE NAME/ADDRESS OF ANY WITNESSES TO THE INCIDENT)

(Attach a separate page for additional information)

Report Submitted By:
Name (print):

__Bob Smith_______________________________

Title:_Administrator _________________

Vendor Name:

__Acme Corporation________________________

Vendor Number:__H36600_____

DHS / CCL Lic#:

_#366000000_______________________________

Signature/Date:

____________________________________________________________________________________

Telephone Number:_(805) 555-1222______

COMPLETE FRONT/BACK CONFIDENTIAL CLIENT INFORMATION W&I CODE, SECTION 4514

10/2006