# Nursing home incident report template

> A nursing home incident report built around what surveyors check. It covers resident and family notice, physician contact, protective steps and the five-working-day result. An abuse and unexplained-injury screen ties to the two-hour and 24-hour clocks. Use it for falls, elopements, skin injuries, fights between residents and other events.

Source: https://incidentkit.ai/templates/nursing-home-incident-report · Updated Oct 5, 2026

## When to use it

- A resident has an accident, fall, injury, elopement, choking episode or other surprise event.
- An injury is found and no one knows how. It may be an injury of unknown source.
- A resident, family member or staff member alleges, or you suspect, abuse, neglect, exploitation, mistreatment or missing property.
- A fight between residents, or a behavior event, puts a resident at risk.
- A change in condition after an event needs physician and family notice, with times.

## The template

### 1. Resident and event

- Resident name, room and unit
- Resident ID or medical record number
- Date of event
- Time of event
- Time found, if different (Key for unwitnessed events.)
- Where it happened: Resident room / Bathroom / Hallway / Dining room / Therapy area / Outdoors or courtyard / Transport vehicle / Other
- Event type: Fall or near-fall / Injury of unknown source / Skin tear or other injury / Elopement or missing resident / Choking or aspiration / Medication event / Resident-to-resident incident / Alleged abuse, neglect or mistreatment / Missing property / Equipment or environmental hazard / Behavior or self-harm / Other

### 2. Abuse and reporting screen

- Is there an allegation or suspicion of abuse, neglect, exploitation, mistreatment or theft of property? (If yes, call the administrator now. Finish this form later. Federal rules (42 CFR 483.12(c)(1)) give 2 hours from the allegation for abuse or serious bodily injury, and 24 hours otherwise.): Yes / No / Unsure: ask the administrator before continuing
- Is this an injury of unknown source? (All three: no one saw it, the resident cannot explain it, and it looks suspicious (size, place or number).): Yes: all three criteria apply / No / Not an injury
- Serious bodily injury? (CMS: extreme pain, major risk of death, long loss of function, or injury needing surgery, hospital care or rehab.): Yes / No / Unknown
- Date and time the allegation was made or the suspicion formed (This starts the reporting clock. Limits run on real clock time, not business hours.)
- Reported to administrator (name, date, time)
- Reported to State Survey Agency, adult protective services or law enforcement (agency, date, time, confirmation number) (A suspected crime has 2-hour and 24-hour limits too. State rules may be shorter.)
- Resident protected from further harm while the investigation is open (Separate the people involved, change assignments or add supervision (42 CFR 483.12(c)(3)).)

### 3. What happened

- Description of the event (What you saw, heard and did, in order. Quote the resident. No opinions.)
- Witnessed?: Witnessed / Unwitnessed: resident found / Unknown
- Last time the resident was seen before the event, and by whom (Needed for any unwitnessed event.)
- Staff and others present or nearby
- Resident's explanation, if any (Use their words. If they cannot explain, say why.)

### 4. Resident condition and injury

- Injuries found (location, size, color, description) (Measure in cm. Note bruises, skin tears, swelling, deformity and pain on movement.)
- Injury level: None / Minor: first aid only / Moderate: needs a doctor's exam or treatment / Major: fracture, head injury or hospital transfer / Death
- Vital signs and pain score after the event
- Mental status compared with usual (A change may need immediate notice.): Same as usual / Changed: describe in the story
- Treatment given
- Transferred to hospital?: No / Yes: emergency / Yes: scheduled evaluation

### 5. Notifications

- Physician or nurse practitioner notified (name, date, time, orders received) (You must consult the physician right away for an accident with injury that may need physician care (42 CFR 483.10(g)(14)).)
- Resident representative or family notified (name, relationship, date, time, by whom) (The same rule covers the representative. Record every try if you cannot reach them.)
- Resident informed in terms they can understand
- Director of nursing notified (date, time)
- Medical director notified, if indicated (date, time)
- Other state or local reports (state incident reporting, ombudsman) (States set their own rules and deadlines. Check yours.)

### 6. Immediate actions and care plan

- Immediate actions taken
- Interim safety measures started today (Say what changed now: supervision, device, room, toileting schedule, bed height.)
- Care plan updated
- Risk assessment updated (fall, elopement, skin or behavior)
- Staff briefed (shift, date)

### 7. Investigation

- Investigation lead and start date
- Findings: contributing conditions (List system conditions, not blame. Keep fact apart from opinion.)
- Conclusion: Violation confirmed / Violation not confirmed / Accident: avoidable / Accident: unavoidable / Still under review
- Date results reported to administrator and State Survey Agency (Due within 5 working days of the incident (42 CFR 483.12(c)(4)). If a violation is verified, corrective action is required.)
- Corrective action taken or planned (owner and due date)
- Entered in the QAA/QAPI event log

### 8. Sign-off

- Completed by (name and title)
- Signature of person completing the report
- Director of nursing or administrator review
- Date reviewed

## How to fill it out well

1. If abuse or an unexplained injury is possible, start at section 2. Call the administrator first.
2. Record clock times, not just dates. The 2-hour and 24-hour limits run from the moment of the allegation.
3. Quote the resident's own words and note who was there. Report abuse allegations before judging if they are credible.
4. Document every notice try, including unanswered calls, with the time.
5. Write interim safety steps the same day. The care plan update should match what staff do.
6. Keep witness statements, findings and corrective action together so the five-working-day report is easy to send.
7. Give the completed report to the director of nursing or administrator by the end of the shift.

## Tips

- Report an allegation first, then investigate. CMS says do not judge if it is credible before reporting.
- A fall without injury is still a fall. CMS counts a resident found on the floor as a fall unless evidence shows otherwise.
- Review events by shift, location and time of day. The QAA committee needs to see patterns.
- Use the [fall incident report](https://incidentkit.ai/templates/fall-incident-report) for extra fall detail: footwear, device, activity and the post-fall huddle.

## Frequently asked questions

### How fast must a nursing home report suspected abuse?

Under 42 CFR 483.12(c)(1), report abuse, or an allegation with serious bodily injury, within 2 hours. Report neglect, exploitation or theft without serious bodily injury within 24 hours. Tell the administrator and State Survey Agency, plus others under state law. Results are due in 5 working days.

### What is an injury of unknown source?

CMS uses the term when three things are true. No one saw how it happened. The resident could not explain it. And it looks suspicious by size, place (an area not usually hurt) or number. It is treated as an alleged violation, on the same clocks.

### Who must be notified when a resident has an accident?

If an accident causes injury that may need a physician, act right away (42 CFR 483.10(g)(14)). Tell the resident, consult the physician and notify the resident representative. The same goes for a significant change in condition, a major treatment change, or a transfer or discharge decision.

### Who has to report a suspected crime against a resident?

Covered individuals must report a reasonable suspicion of a crime against a resident to the State Agency and local police. They are the owner, operator, employee, manager, agent or contractor of a federally funded long-term care facility. The limit is 2 hours with serious bodily injury, 24 hours without. Facilities must tell them of this duty yearly.

## Sources

- [eCFR: 42 CFR 483.12, Freedom from abuse, neglect, and exploitation](https://www.ecfr.gov/current/title-42/section-483.12)
- [eCFR: 42 CFR 483.10, Resident rights (notification of changes, paragraph (g)(14))](https://www.ecfr.gov/current/title-42/section-483.10)
- [CMS State Operations Manual, Appendix PP: Guidance to Surveyors for Long Term Care Facilities (F580, F609, F610, F689)](https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf)
- [eCFR: 42 CFR 483.25, Quality of care (accidents, paragraph (d))](https://www.ecfr.gov/current/title-42/section-483.25)

## Related

- [Incident reporting software for skilled nursing facilities](https://incidentkit.ai/solutions/skilled-nursing-facilities)
- [Nursing home abuse reporting: 2-hour and 24-hour rules](https://incidentkit.ai/compliance/reporting-deadlines/abuse-and-neglect-reporting)
- [F609 reporting alleged violations: 2-hour and 24-hour rules](https://incidentkit.ai/compliance/f-tags/f609)
- [F689 accidents and supervision: falls, hazards, devices](https://incidentkit.ai/compliance/f-tags/f689)
- [Abuse Reporting Deadlines for Nursing Homes: 2 and 24 Hours](https://incidentkit.ai/use-cases/abuse-reporting-deadlines)
- [Fall Incident Report Template for Healthcare (Printable)](https://incidentkit.ai/templates/fall-incident-report)