Investigation Report

After conducting an internal investigation, submit a report of the investigation to DHHS. The form below may be used for your investigative report. Please put NA on lines not pertinent to your investigation. The following should be reported to APS, investigated and investigative report submitted to DHHS:

  • Abuse: physical, sexual, verbal, mental, psychosocial
  • Neglect: deprivation of goods or services
  • Other: injuries of unknown origin, misappropriation, fall/accident with significant injury, elopement, resident to resident altercation, exploitation, etc

Facility Details

Notification to Administrator / Director of Nursing

Law Enforcement Notified

Who was involved in the incident? (Information about Resident(s) e.g., BIMS, ADLs, Dx)

Resident(s) name Birth Date Gender/Resident Info

Non-Resident(s) Involved

Non-Resident(s) Name Address Relationship to Non-Resident Phone

Was Staff Involved?

Describe the Incident (date, time, details of positioning, etc.)

Type of Injury / Effect on Resident (Provide details of any physical harm, pain or mental anguish)

Did the injury require medical attention?

What immediate steps were taken to protect the resident(s)

Were there any witnesses to the incident?

Are there any patterns or trends related to this incident involving the same resident(s) or others?

Investigation Summary and Outcome (Include observation records, reviews, interventions, causal factors)

What permanent steps were put into place to prevent recurrence?

Other Notifications Completed:

Provider
POA / Guardian
Family

Send additional supporting information related to this report as a single document to: DHHS.HealthFacilityInvestigations@Nebraska.gov