The Facility will establish a consistent documentation and reporting process, in consideration of all federal/state laws and regulations and define those incidents that require reporting.


To define the types of incidents/variances to be reported in consumers and employees as well as the process for reporting.


Health Facilities and Emergency Medical Services Division, 10 CCR 2505-10 8.491

Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for Hospitals and Health Facilities, Chapter 2 – General Licensure Standards, Section 3.2


“Incident/Occurrence Log,” “Incident/Occurrence Report: Consumer or Employee” forms


  1. The Facility will document and report all incidents/occurrences (accidents, injuries, safety and security hazards) that deviate from routine Facility operations and will result in injury or potential harm to a consumer/caregiver or Facility staff. Such incidents may include, but are not limited to:
    • Security issues resulting in injury or identifying the potential for harm.
    • Equipment and/or medical device failure with resulting injury or harm.
    • Equipment and/or medical device failure with resulting injury or harm.
    • Endangerment of staff and/or consumers.
    • Procedure error which results in trauma and/or injury.
    • Medication errors.
    • Any staff accidents that require treatment, lost work days, hospitalization or that identify new safety hazards that were previously unrecognized.
    • Alleged/suspected consumer abuse.
    • Unexpected consumer death.
    • Witnessed consumer falls.
    • Sentinel events.
  2. The Facility will not discharge or in any manner discriminate or retaliate against any consumer, relative, legal representative or sponsor thereof, or any other person because such person, relative, legal representative, sponsor, or employee has made in good faith or is about to make in good faith, a report pursuant to this section or has provided in good faith or is about to provide in good faith evidence in any proceeding or investigation relating to any occurrence required to be reported by the Facility.
  3. No copies will be made of incident/occurrence reports and confidentiality of involved individuals will be maintained.


  1. An Incident/Occurrence Report: Consumer or Employee will be completed on all incidents, as defined in policy, by the staff member involved or the first person to become aware of the incident.
  2. The report will be submitted to the Facility Director, who is responsible for immediate investigation of the incident and taking any appropriate action, including instituting appropriate measures to prevent similar future occurrences.
  3. The Facility Director will review the Incident/Occurrence Report: Consumer or Employee and will document awareness of the incident, adding it to the incident log.
  4. The Facility Director will determine the appropriateness of reporting the occurrence to the CDPHE and will ensure compliance with all reporting requirements of 6 CCR 1011-1, Chapter 2, section 3.2.
    • Documentation regarding the investigation, including appropriate measures to be instituted, shall be made available to the CDPHE, upon request.
    • A report with the investigation findings shall be available for review by the CDPHE within five (5) working days of occurrence.
    • The Facility shall ensure that all staff have knowledge of Article 3.1 of Title 26, C.R.S. regarding protective services for at-risk adults, and that all incidents involving neglect, abuse or financial exploitation are reported immediately, through established procedures, to the Facility Administrator or manager.
      • The Facility shall report the incident to the appropriate officials as specified in the statute and, if applicable, to the CDPHE as an occurrence. The facility shall make copies of all such reports available to the department upon request.
      • The Facility shall document that all alleged incidents involving neglect, abuse or health professional misconduct are thoroughly investigated in a timely manner.
  5. The Facility will continue to provide the consumer with the care agreed upon in the service agreement during the investigation, unless the consumer or consumer’s representative requests discontinuation of services, or if continuation of services would place the consumer or employee at risk.
  6. The supervisor will assure all applicable federal/state reports/forms are completed, e.g., OSHA 300 Log, as needed.
  7. The Incident/Occurrence binder will be maintained with the incident reports and the incident log. Quarterly, the log will be reviewed, and any trends identified will be documented on the quarterly audit performance plan.