Certus Claims Fax: 1-805-987-8806 Incident InvolvedResidentVisitorEmployee (reason for being in location ) Time of Incident:ampm RESIDENT/VISITIOR/EMPLOYEE INFORMATION: Gender:MaleFemale Payor Source:Private PayMedicareMedicaid Assistive devices in use?WalkerCaneWheelchair Resident has a history of falls?YesNo Resident Condition before incident:ConfusedNormalDisorientedSedated Shift:Day: (6 am-6 pm)Evening: (6 pm - 12 am)Night: (12 am-6 am) Physical or Chemical Restraint in use?YesNo Type:PhysicalFull Bedrail1/2 side railOther If chemical or sedated with hypnotic or behavioral drug: Exact Location of Incident / Accident:Resident RoomHallwayBathroomDining RmPatioShowerDrivewayActivity RmLiving RoomOther Are Dr's orders in place for restraints?YesNo Order renewed & re-evaluated every six months?YesNo Vital Signs: Loss of consciousness Was Equipment involved?YesNo Recurrent incident in 6 mths?YesNo Type of Incident:Witnessed FallFound on floorTransferringBehavioral aggressiveAbuse Neglect or ExploitationEquipment MalfunctionElopementMedication ErrorTheftVandalismUnknown Outcome:No InjurySurgeryERAdmitted to HospitalD/C to Higher Level of Care Death if yes, was case referred to ME:YesNo Injury:YesNo Cut/laceration / Skin Tear/ AbrasionBruise/ BleedFracture/DislocationBurnSprain / StrainSwellingMedication Related Reported to State: YesNo Police called:YesNo Reported to Abuse:YesNo Witnessed or Responded to by: Treatment:None NEEDED1st aide @ FacilityERAdmitted HospitalDr. officeOther (name and relationship to resident) Physician Called & Notified:
