Aas 45 2025

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The document is a Reportable Event Record/Report form from the New Jersey Department of Health and Senior Services, specifically for the Division of Long Term Care Systems. It is designed to report significant events occurring in various types of long-term care facilities, such as nursing homes and assisted living centers. The form requires detailed information about the event, including its nature, location, involved individuals, prior care plans, interventions taken post-incident, and necessary notifications. It emphasizes thorough documentation for compliance and investigation purposes.

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Click ‘Get Form’ to open the aas 45 in the editor.
Begin by entering today’s date in the specified format (MM/DD/YY) at the top of the form.
Indicate whether this was a significant event by selecting 'Yes' or 'No'.
Fill in the date and time of the event, ensuring you select AM or PM as appropriate.
Provide details about the facility, including its full name, address, telephone number, license number, and provider ID.
Select the type of facility from the provided options and specify if necessary.
Describe the exact location of the incident and select the type of incident from the list provided.
Complete sections regarding resident information, narrative description of the event, prior care plans, and post-event interventions.
If applicable, provide nurse aide involvement details including certification numbers and expiration dates.
Finally, complete any notifications made and leave space for NJDHSS review comments at the end of the form.

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