Nevada Medicaid Critical Incident Report Form

Types of Potential Critical Incidents (check all that apply):

Homicide or attempted homicide by the member Major injury or major trauma that has the potential to cause prolonged disability or death of a member that occurs at a facility licensed by the State to provide publicly funded Behavioral Health Services An unexpected death of a member that occurs in a facility licensed by the State to provide publicly funded Behavioral Health Services Abuse, neglect, exploitation or unexpected death of a Member (not to include child abuse) Any event involving a member that has attracted or is likely to attract media attention Violent acts allegedly committed by member (arson, assault resulting in serious bodily harm, homicide or attempted homicide by abuse, drive by shooting, extortion, kidnapping, rape, sexual assault, indecent liberties, robbery or vehicular homicide) Unauthorized leave of mentally ill offender or a sexual or violent offender from a mental health facility, secure Community Transition Facilities (i.e., Evaluation and Treatment Centers, Crisis Stabilization Units, Secure Detox Units and Triage Facilities) that accept involuntary admissions

Provider/Facility Information

Provider/Agency Name:

National Provider Identifier (NPI):

Phone Number:

Provider Address:

City:

State:

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Zip Code:

Reporting Party

Reporter’s First Name:

Reporter’s Last Name:

Title:

Phone Number:

Email Address:

Point of Contact to Discuss Incident (if different from reporter)

First Name:

Last Name:

Phone Number:

Member Information:

Medicaid ID Number:

Member First Name:

Member Last Name:

Date of Birth:

Age:

Member Address:

City:

State:

--Select State-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Incident Details

Date Incident Occurred:

Date Incident Discovered:

Incident Location (If other, specify):

Member’s Residence:

Living alone

Living with relative(s)

Living with unrelated person

Residential Care Facility

Assisted Living

Other

Community:

Work

School

Vehicle

Day Program

Other

Other Location:

State Facility

Nursing Facility

Hospital or Clinic

PMIC

Correctional Facility or Jail

Other

Residence Other:

Community Other:

Other's Value:

Description of Incident:

Involved Persons/Witness

Indicate persons involved during incident. Include names, relationships (if other, specify) and title of facility personnel.

Name:

Relationship:

Staff Family Other

Other

Title:

Add Another Person

Member’s Whereabouts at the Time of the Report (if known):

Member’s Residence Jail Hospital Unknown

If unknown, actions planned to locate member