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Date:ProgramPerson SupportedType of Incident
Level of Incident
Incident Report Received TimelyIf Level 2/3 Date reported to RCIf A/N/M related or UO, Date Reported to CDPHEmployee Involved or On-DutyPersonnel Action TakenRoot Cause NeededDate: Root Cause CompletedIdentified Root CauseDate family/AR NotifiedCDPH or RC Actions TakenPOC NeededCorrective Action Fully ImplementedAdditional Information and Follow-Up
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1/12/2022ABC HomeJohn DoeFall without injury1YesN/AN/AJane SmithNoNoN/AN/A012 JanN/AN/AN/AJohn tripped over his slipper, no injuries noted. He reported he did not hurt. Staff Monitored
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1/16/2022DEF HomeJodi JonesER Visit 2Yes16-JanN/AMike DarrellNoYes2/12/2022Not hydrated enogh16-JanN/AN/AN/AJodi is not drinking enough water. RN will write protocol and train staff.
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1/26/2022GHI HomeSam GreerAlleged Abuse3Yes1/27/20221/27/2022Janet DunnYes staff suspendedYes2/17/2022Staff acted on own accord, was trained and understood she violoated policy027 JanYesYesPendingJanet threatened Sam with no dinner if he did not behave better. She also took away his crossword puzzle and would not give it back. Sam reported she slapped his arm.
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