Form 6107, Psychiatric Hospital Incident Report

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Effective Date

10/2024
6107.pdf

Instructions

Effective Date: 10/2024

Purpose

Form 6107 is used to notify Texas Health and Human Services Commission (HHSC) of an incident and the actions taken by the facility.

Procedure

Submit each form separately within the required time frame of the incident:

  • Abuse
  • Neglect
  • Illegal, unprofessional or unethical conduct that relates to the operation of the facility or its services
  • Emergency Medical Treatment and Active Labor Acts (EMTALA) Violations

Do not submit multiple incidents in one document.
Explain how the facility will improve care as a result of the incident. Complete the entire form with all requested attachments so HHSC can review the incident without requiring additional information or documents.

Transmittal

Submit each completed form by one of the following:

Email: CII.HCQ@hhs.texas.gov
Fax: 833-709-5735 or 512-206-3985
Mail: Texas Health and Human Services Commission
Complaint and Incident Intake
P.O. Box 149030, Mail Code E-249
Austin, TX 78714-9030

Detailed Instructions

Print or type the information and provide as much information as possible. Use the facility name and license number as listed on your license.
Reportable Incident – Check the appropriate box from the following:

  • Abuse
  • Neglect
  • Illegal, unprofessional or unethical conduct related to operation of facility or services
  • Emergency Medical Treatment and Active Labor Acts (EMTALA) Violations

Date of Report – Enter the report date.

Date of Incident – Enter the date of the incident.

Time of Incident – Enter the time of the incident and check AM or PM.

Facility License No. – Enter the facility license number.

Facility Provider No. (CCN) – Enter the facility provider number, which is your six-digit Medicare number.

Facility Name – Enter the name of the facility.

Area Code and Phone No. – Enter the area code and telephone number.

Address – Enter the street address, city, state, ZIP Code.

Reporter Name and Title – Enter the contact person and title the surveyor will ask for should a follow-up phone call be needed.

Primary Area Code and Phone No. and Area Code and Secondary Phone No. – Enter the area code and phone numbers.

Email – Enter the email address.

Patient 1 Name – If the incident involves a patient enter the first, middle and last name.

Date of Birth – Enter the patient's date of birth.

Date of Admission – Enter the date the patient was admitted.

Date of Discharge – Enter the date the patient was discharged.

Patient Resides in Hall, Unit, Floor, Room – Name, hall number or name, room number, floor number where the patient resides.

Date of Death- Enter the date the patient died.

Expected Cause of Death – Enter the expected cause of death.

Medical and Psychiatric Diagnoses – Enter the diagnoses.

Level of Supervision at the time of the incident - Enter the patient’s level of supervision.

Discharge Disposition – Check the box for home, hospital or other. If other enter the other disposition.

Transfer Facility Name and City – Enter the name of the facility and city.

Medical Provider Name - Enter the name of the medical provider that provided medical services to the patient.

Title - Enter the title of the medical provider.

License No. – Enter the license number of the medical provider.

Did the patient sustain any injuries? – Check Yes or No. If yes explain.

Did the patient receive any treatment while at the psychiatric hospital? – Check Yes or No. If yes explain.

Were restraints used? Check Yes or No. If yes provide the type of restraint and the physician order.

If the patient was transferred to a hospital what was the hospital discharge date? Enter the date the patient was discharged and transferred.

Provide the outcome of the hospital transfer. Include any treatment provided. Enter the outcome result of the patient transfer.

Were any diagnostic tests performed such as X-ray, CT scan, MRI, ultrasound, PET scan, blood work or other? – Check Yes or No. If yes, provide diagnostic test results.

Does the patient have a history of elopements, suicidal ideations or attempts, behaviors including self-harm, unfounded allegations or other? – Check Yes or No. If yes explain.

Was a psychiatric assessment performed? Check Yes or No. If yes provide the psychiatric assessment results

Is the patient under emergency detention order? Check Yes or No.

Patient 2 Name – If the incident involves another patient, enter the first, middle and last name.

Date of Birth – Enter the patient's date of birth.

Date of Admission – Enter the date the patient was admitted.

Date of Discharge – Enter the date the patient was discharged.

Patient Resides in Hall, Unit, Floor, Room – Name, hall number or name, room number, floor number where the patient resides.

Date of Death- Enter the date the patient died.

Expected Cause of Death – Enter the expected cause of death.

Medical and Psychiatric Diagnoses (all) – Enter the diagnoses.

Level of Supervision at the time of the incident- Enter the patient’s level of supervision.

Discharge Disposition – Check home, hospital or other. If other enter the other disposition.

Transfer Facility Name and City – Enter the name of the facility and city.

Medical Provider Name - Enter the name of the medical provider that provided medical services to the patient.

Title - Enter the title of the medical provider.

License No. – Enter the license number of the medical provider

Summary

When did you first learn of the incident? – Enter the date and time.

On what shift did the incident occur? – Check day, evening or night.

Provide a summary – Enter what happened, who was involved such as an RN, LVN, PCT, MD or other and the action taken at the time of the incident.

Did the patient sustain any injuries? – Check Yes or No. If yes explain.

Did the patient receive any treatment while at the psychiatric hospital? – Check Yes or No. If yes explain.

Were restraints used? Check Yes or No. If yes provide the type of restraint and the physician order.

If the patient was transferred to a hospital what was the hospital discharge date? Enter the date the patient was discharged and transferred.

Provide the outcome of the hospital transfer. Include any treatment provided. Enter the outcome result of the patient transfer.

Were any diagnostic tests performed such as X-ray, CT scan, MRI, ultrasound, PET scan, blood work or other? – Check the box for Yes or No. If yes, provide diagnostic test results.

Does the patient have a history of elopements, suicidal ideations or attempts, behaviors including self-harm, unfounded allegations or other? – Check Yes or No. If yes explain.

Was a psychiatric assessment performed? Check Yes or No. If yes provide the psychiatric assessment results

Is the patient under emergency detention order? Check Yes or No.

Note: Attach additional sheet(s) for additional patients involved if necessary.

Witness Name – Enter the name of the witness. Witnesses can include other patients, staff members, family members or friends.

Title - Enter the title of the witness if the witness is a staff member.

Area Code and Phone No – Enter the phone number of the witness

Alleged Perpetrator 1 Name and Title – Enter the alleged perpetrator's name and title. List only alleged perpetrators who are not patients. List alleged perpetrators who are patients in the Patient section. If the alleged perpetrator is neither a patient nor a staff member, indicate the relationship of this person to the patient such as a friend or family member.

Alleged Perpetrator 1 License No. – Enter the alleged perpetrator's license number.

Social Security No. – Enter the alleged perpetrator's Social Security number.

Area Code and Phone No. – Enter the alleged perpetrator's area code and phone number.

Address – Enter the alleged perpetrator's street address, city, state and ZIP Code.

Alleged Perpetrator 2 Name and Title – Enter the alleged perpetrator's name and title. List only alleged perpetrators who are not patients. List alleged perpetrators who are patients in the Patient section. If the alleged perpetrator is not a patient or a staff member, indicate the relationship of this person to the patient such as a friend or family member.

Alleged Perpetrator 2 License No. – Enter the alleged perpetrator's license number.

Social Security No. – Enter the alleged perpetrator's Social Security number.

Area Code and Phone No. – Enter the alleged perpetrator's area code and phone number.

Address – Enter the alleged perpetrator's street address, city, state and ZIP Code.

Note: Attach additional sheet(s) for additional alleged perpetrators involved if necessary.

Provide a narrative report of the investigation – Explain how you handled the incident and what actions you will take to reduce the potential for similar incidents in the future.

Referrals – Check all boxes that apply and the report number for each.

Actions to be taken as a result of this incident – Check all boxes that apply.

Signature, Printed Name and Date – The supervising authority signs, prints their name and enters the date. Email, fax or mail the completed incident form to the number or address under Transmittal.

Summary

When did you first learn of the incident? – Enter the date and time.

On what shift did the incident occur? – Check the box for day, evening or night.

Provide a brief summary – Enter what happened, who was involved (e.g., RN, LVN, PCT, MD, other), and the action taken at the time of the incident.

Was this reported to law enforcement? – Check Yes or No.

Was this reported to another organization? – Check Yes or No. If yes, provide the name of the organization.

Provide a narrative report of the investigation – Explain how you handled the incident and what actions you will take to reduce the potential for similar incidents in the future.

Actions to be taken as a result of this incident – Check all boxes that apply.

Signature, Printed Name and Date – The supervising authority signs, prints his/her name and enters the date. Then, email, fax or mail the completed incident form to the number or address provided above under Transmittal.