This page provides a list of all questions found on the PSRP reporting form for nursing facilities. They are grouped alphabetically by the section of the form in which they appear. This list does not indicate which questions are required for all nursing facility reports nor which questions only appear for certain event types. A list of required questions can be found here: Required Fields for Nursing Facilities.

General Information

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  Age unit (ASC, Nursing Facility, Pharmacy)
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  Contact email address
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  Contact extension
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  Contact name
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  Contact phone
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  Date discovered
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  Event date
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  Event time
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  Event time unknown
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  Form ID
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  Last modified date
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  Patient age
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  Patient ethnicity
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  Patient gender (ASC, Hospital, Nursing Facility)
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  Patient race
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  Select your facility (Nursing Facility)
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  Submission date
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  When was the DNS or administrator notified of the event?
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  Who should we contact for clarification or feedback?

Summary, Cause and Action Plan Information

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  Action plans
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  Causes
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  Event Summary
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  Is this a root cause?

Harm Category

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  Did an actual adverse event occur?
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  Did the event contribute to or result in patient death?
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  Did the event reach the patient?
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  Did the event require any of the following significant interventions? (Nursing Facility)
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  The Harm Category for this event is
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  Was an intervention necessary to sustain life required?
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  Was extra monitoring or an intervention to preclude harm required?
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  Was the harm permanent?
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  Was the harm temporary?
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  Was the patient harmed?
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  What prevented the event from reaching the patient? (ASC, Hospital, Nursing Facility)
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  What was the extent of harm to the patient?
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  Which intervention to preclude harm was required? (Hospital and Nursing Facility)

Event Information

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  Event location (Nursing Facility)
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  Event type (Nursing Facility)
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  How preventable was the incident?
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  Level of care
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  Relevant comorbidities
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  Relevant surgeries or procedures

Event Type-Specific Questions

Device, Equipment or Supply Event-Specific Questions

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  Specific device
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  Type of device or supply involved (Nursing Facility)
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  Which best describes the event?

Fall Event-Specific Questions

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  Date of most recent fall risk assessment
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  Did any physical device contribute to the fall?
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  Did the patient/resident sustain a physical injury as a result of the fall? (Nursing Facility)
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  Prior to the fall, what was the patient doing or trying to do? (Nursing Facility)
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  Was a fall risk assessment documented?
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  Was the fall assisted or unassisted?
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  Was the fall observed? (Nursing Facility)
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  Was the medication considered to have contributed to the fall?
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  Was the patient/resident assessed to be at any level of risk for a fall? (Nursing Facility)
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  Was the patient/resident on medication known to increase fall risk at the time of the fall? (Nursing Facility)
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  Were any of the following risk factors considered to have CONTRIBUTED to the fall?
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  Were any of the following risk factors present at the time of the fall?
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  What type of injury was sustained?
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  What was the patient/resident’s goal? (Nursing Facility)
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  What was the physical or environmental cause of the fall?
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  Which of the following were in place and being used to prevent falls for this patient/resident? (Nursing Facility)
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  Which of the following were in the patient’s care plan to prevent falls? (Nursing Facility)
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  Why was the most recent fall risk assessment performed? (Nursing Facility)

HAI Event-Specific Questions

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  Type of central line involved
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  Type of healthcare-associated infection (HAI) (Nursing Facility)
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  Type of pathogen
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  Was the infection determined to be present or incubating on admission?

Medication or Other Substance Event-Specific Questions

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  At what stage in the process did the event originate, regardless of the stage at which it was discovered? (ASC, Hospital, Nursing Facility)
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  Generic name or investigational drug name
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  Type of medication or other substance event (ASC, Hospital, Nursing Facility)
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  Type of other substance (Nursing Facility)
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  Was this medication/substance given to this patient?
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  Was this medication/substance prescribed for this patient?
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  Were any of the following involved? (Nursing Facility)
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  What type of medication/substance was involved? (ASC, Hospital, Nursing Facility)
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  What was the actual route of administration? (Nursing Facility)
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  What was the contraindication (potential or actual interaction)?
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  What was the intended route of administration? (Nursing Facility)

Pressure Injury Event-Specific Questions

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  Most advanced stage of pressure injury being reported
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  On admission to the facility, was a skin inspection documented?
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  Pressure injury location on the body
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  Type of risk assessment performed
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  Was any preventive intervention implemented?
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  Was the patient/resident assessed to be at any level of risk for a pressure injury?
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  Was the use of a device or appliance involved in the development or advancement of the pressure injury?
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  What was the stage of the pressure injury on admission?
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  What was the type of device or appliance? (Nursing Facility)
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  When was the first pressure injury risk assessment documented?

Contributing Factors

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  Communication factors (Nursing Facility)
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  Contributing Factor Category: Communication
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  Contributing Factor Category: Device, Equipment, or Supply
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  Contributing Factor Category: Human or Environmental
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  Contributing Factor Category: Organizational
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  Contributing Factor Category: Patient/Resident (Nursing Facility)
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  Contributing Factor Category: Patient/Resident Management (Nursing Facility)
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  Contributing Factor Category: Policy or Procedure
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  Device, equipment, or supply factors (Nursing Facility)
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  Human or environmental factors (ASC, Hospital, Nursing Facility)
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  Organizational factors (Nursing Facility)
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  Patient/Resident factors (Nursing Facility)
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  Patient/resident management factors (Nursing Facility)
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  Policy or procedure factors (ASC, Hospital, Nursing Facility)

Review and Analysis Information

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  Date review and analysis completed
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  Did the review and analysis team have a post-analysis briefing with the interdisciplinary team? (Nursing Facility)
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  Members of the review and analysis team (Nursing Facilities)
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  Person hours spent in review
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  Please specify why no written notification was given
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  Who was given written notification? (Nursing Facility)
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  Why was your facility unable to provide written notification?