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New Incident Report
Client Information
Client First Name
Client Last Name
DOB
Incident Location
The Oaks
Rita Thompson Residence
Richcraft Residence (Montreal Rd)
Carruthers
Cornerstone Booth Residence
Diane Morrison Hospice
Men's Special Care Unit
TED
Outreach
Community
Merivale Rd
Incident Type
Incident Type
Fall or minor accident – injury
Fall or minor accident – no injury
Medication error – administration
Medication error – not documented correctly
Safety/security/conduct
Skin/tissue laceration or abrasion
Medical emergency or overdose
Emergency - no ems called
Emergency – resulting in death/client found deceased
Emergency - ems called
Overdose – not resulting in death
Overdose – resulting in death
Assault/violence/fight or other security incident as a result of incident
(Check all that apply)
Police Or Security Was Called
Police Or Security Not Called
Client Injured
Staff Injured
Other
Did an injury occur to the client?
Yes
No
If yes, nature of injury
Client was sent to emergency
Police or security removed client from premises
Incident Details
Incident Reported By
Incident Submitted By
Copy to (optional)
Location of Incident
Room/Bed
Hall
Common Area
Outside
Kitchen
Office
Other
Date of Incident
Time of Incident
Date Reported to carefor or Manager
Incident Description
What happened? What did you see?
What contributed to this incident?
What were the immediate actions taken? (vital signs, monitoring, notifications, transfers to hospital)...
What can we do to make sure this does not happen again with this or other clients?
Overdose Section
Overdose detail
Suspected Injection
Suspected Smoking
Unknown
Scale 1-10: How intense was this overdose for you and your team to deal with?
1
2
3
4
5
6
7
8
9
10
Number of times Narcan was used
Oxygen used
Yes
No
Naloxone used
Yes
No
Other treatment type
Yes
No
Client outcome
Please access the staff portal and complete a staff incident report in addition to this report.
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