Fillable San Diego Regional Center SPECIAL INCIDENT REPORT SECTION

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San Diego Regional Center SPECIAL INCIDENT REPORT SECTION

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San Diego Regional Center
SPECIAL INCIDENT REPORT
(For SDRC Vendors and Long Term Care Facilities)
(Retain copy of this report in consumer’s file, Notify CCL/SDRC within 24 hours of occurrence
of incident and submit to SDRC written report within 48 hours and to CCL within 7 days of occurrence)
TO: , SDRC Service Coordinator
SECTION I
Consumer’s Name: UCI#:
Date of Birth:
Age: Gender: M F_____
Date of Incident: Time of Incident: ______________________
Date Reported to SDRC/Lic. Agency:
Date of Admission to Facility:
Location of Incident:
[ ] Home of Family/Consumer [ ] Consumer’s Residence [ ] Day program [ ] In-Patient hospice [ ] Job site
[ ] In Transit (Vehicle) [ ] ER of Acute Hospital [ ] Community [ ] Acute Hospital, not ER [ ] School
[ ] Other (Please specify)________________________________________________________________________________________
Please indicate below the name of the place where the incident occurred. (Ex: Name of transportation, name of job site, name of foster home):
______________________________________________________________________________________________________________________
SECTION II
TYPE OF SPECIAL INCIDENT
[ ] Death - Regardless of cause or location
[ ] Missing Person – law enforcement notified
Consumer a victim of crime:
[ ] Burglary
[ ] Larceny
[ ] Robbery
[ ] Rape or attempt to rape
[ ] Aggravated assault
Reasonably Suspected Abuse or Exploitation:
[ ] Physical abuse
[ ] Fiduciary abuse
[ ] Sexual abuse
[ ] Mental/emotional abuse
[ ] Physical/chemical restraint
Reasonably suspected neglect including failure to:
[ ] Provide medical care
[ ] Prevent malnutrition
[ ] Protect from health and safety hazard
[ ] Assist in personal hygiene/provide food,
clothing and shelter
[ ] Exercise the degree of care that a reasonable
person would exercise in the position of having
the care and custody of a elder or a dependent
adult.
A serious injury or accident requiring medical treatment
including:
[ ] Fracture
[ ] Dislocation
[ ] Laceration requiring sutures/stitches
[ ] Puncture wound requiring medical attention beyond
first-aid
[ ] Bites that break the skin requiring medical attention
beyond first-aid
[ ] Burns requiring medical attention beyond first-aid
[ ] Internal bleeding requiring medical attention
beyond first-aid
[ ] Medication reaction requiring medical attention
beyond first-aid
[ ] Any medication error:
Name of medication(s)/dose/frequency:_____________
_______________________________________________
_______________________________________________
Unplanned/unscheduled hospitalization
[ ] Respiratory illness [ ] Seizure related
[ ] Diabetes related [ ] Cardiac related
[ ] Internal infection [ ] Wound/skin care
[ ] Nutritional deficiency/dehydration
[ ] Involuntary psychiatric hospitalization
Other incidents:
[ ] Suicide attempt
[ ] Diagnosis of communicable disease
[ ] Prone/supine containment
[ ] Violation of consumer rights
[ ] Aggressive act to self
[ ] Aggressive act to another consumer
[ ] Aggressive act to staff/family/visitors
[ ] Medical emergency/ER visit/not hospitalized
[ ] Property damage
[ ] Fire/explosion occurring in premises
[ ] Poisoning
[ ] Epidemic outbreak
[ ] Serious illness
[ ] Infestation of parasites/vectors
[ ] Injury accident
[ ] Pregnancy
[ ] Others (specify)_______________________
____________________________________
________________________________
SECTION III Description of Special Incident/Death
(Include conditions prior to incident/death, any consumer/staff involved)
(Please attach a separate page to capture all of the information. If hand writing, please make sure it is legible.)
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
CONFIDENTIAL CLIENT INFORMATION
W&I CODE, SECTION 4524
/staples/glue
SECTION III (continued)
Description of Alleged Perpetrator, if applicable: [ ] Not Applicable
Name:
Relationship to Consumer: [ ] Relative/family member
Height: [ ] Another consumer [ ] Non-vendor/employee of non-vendor
Weight: [ ] Self [ ] Other individual known to consumer
Age: [ ] Unknown [ ] Vendor/employee of vendor
Medical Treatment Provided to Consumer? [ ] Yes [ ] No
If Yes, where?
[ ] Hospital admission [ ] ER [ ] Urgent Care [ ] On Site
Nature of injury/treatment______________________________________________________________________________________________
Follow-up treatment, if any:_____________________________________________________________________________________________
Name and phone number of physician:___________________________________________________________________________________
Name of mortician/funeral home (if applicable):_____________________________________________________________________________
SECTION IV
Action(s) taken by vendor in response to Special Incident:____________________________________________________________________
[ ] Staff training [ ] Policies revised [ ] Staff terminated
[ ] Referral to Clinical Services [ ] Planning Team meeting [ ] Staff suspended
[ ] Reported to other agencies [ ] Review/Revise behavior plan
[ ] Other (please specify)____________________________________________________________________________________________
Plan to prevent further occurrence/anticipated result:________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Comments:____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Name/Address/Phone # of any witness to the incident (if any):_________________________________________________________________
______________________________________________________________________________________________________________________
Consumer is:
☐ Verbal ☐ Non-Verbal ☐ Ambulatory ☐ Non-Ambulatory
SECTION V
Parties/Agencies Notified:
Party/Agency Name of Contact Phone # Date Notified
[ ] APS/CPS _______________________________ ___________________ ___________________
[ ] Law Enforcement _______________________________ ___________________ ___________________
[ ] LTC Ombudsman _______________________________ ___________________ ___________________
[ ] CCL/HDL _______________________________ ___________________ ___________________
[ ] Coroner _______________________________ ___________________ ___________________
[ ] Parent/Conservator/Guardian _______________________________ ___________________ ___________________
[ ] Care Provider/Residence _______________________________ ___________________ ___________________
[ ] Others (please specify) _______________________________ ___________________ ___________________
SECTION VI
Report Written By:
Name:_____________________________________________ Facility/Vendor Name:_________________________________
Title & Signature:____________________________________ Vendor Address:_____________________________________
Reviewed By: ___________________________________________________
Name:_____________________________________________ Vendor Number:______________________________________
Title & Signature:____________________________________ Phone Number:______________________________________
Date:______________________________________________ DHS/CCL License #:__________________________________
PLEASE FAX TO SDRC SERVICE COORDINATOR
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San Diego Regional Center SPECIAL INCIDENT REPORT SECTION

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Completed 22 June 2021

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