"Nursing Facility Required Reporting - Certified Facilities" - Rhode Island

This "Nursing Facility Required Reporting - Certified Facilities" is a document issued by the Rhode Island Department of Health specifically for Rhode Island residents with its latest version released on October 3, 2018.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Rhode Island Department of Health.

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Download "Nursing Facility Required Reporting - Certified Facilities" - Rhode Island

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CHFR 10-3-18
Department of Health, Center for Health Facilities Regulation
1
Nursing Facility Required Reporting
Certified Facilities
Reporting Facility:
Date of Report:
Reported by:
Title:
Contact Number:
Report any suspicion of a crime committed against a resident that results in serious bodily harm within two (2) hours to Law Enforcement and to
the Department via phone (401) 222-5200. All other suspicions of a crime against a resident that does not result in serious bodily harm must be
reported to Law Enforcement and the Department within 24 hours (as defined in Section 1150B of the Social Security Act, as established by section
6703(b)(3) of the Patient Protection and Affordable Care Act, 2010).
Must be reported as defined below:
Abuse, Neglect, Mistreatment & Injuries of Unknown Source:
*Resident to Resident Abuse
Report all alleged violations involving abuse, neglect, exploitation or mistreatment, including
*Staff to Resident(s) Abuse
injuries of unknown source and misappropriation of resident property; immediately, but not later
than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or
*Neglect
result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do
not involve abuse and do not result in serious bodily injury (in accordance with 42 CFR
*Misappropriation / Exploitation
§483.12(c)(1))
*Injuries of Unknown Source
Accidents /Incidents/ Death:
Must be reported within 24 hours or by the next business day, unless otherwise indicated. Please select the most
appropriate:
Accident / incident resulting in hospital admission
Death within 24 hours of admission or prior to physical exam
Accident / incident resulting in death in the facility
Elopement: (Only required if police were notified)
*Accident or incident resulting in death in the
Unscheduled implementation of fire/evacuation/disaster plan.
hospital following an accident
Report immediately via phone (401) 222-5200, then fax this form within
three (3) business days.
*Indicates 5-Day Facility Investigation Report must be faxed to the Department within five (5) business days.
Resident(s) Information:
Last Name:
First:
DOB
Female
Male
Room #
Last Name:
First:
DOB
Female
Male
Room #
Alleged Perpetrator(s) Information (if applicable):
Last Name:
First:
Resident
Non-resident
Staff
Last Name:
First:
Resident
Non-resident
Staff
Has Victim(s) and/or Abuser(s) been involved in previous reportable incidents?
If yes, please describe.
Incident Information:
Date of Incident:
Time:
Location of Incident:
Witness(s):
No
Yes
(Provide names)
Description of incident and immediate action taken to ensure safety of resident(s). Include any resident(s) injury.
CONTINUE ON ADDITIONAL PAGES AS NEEDED
FAX to: Facilities Regulation: (401) 222-3650 or (401) 222-3999 and RI LTC Ombudsman: (401) 785-3391
1
Reports may be called in immediately to DOH-222-5200 and the RILTCOO-785-3340 with follow-up faxes of this form by the next business day.
CHFR 10-3-18
Department of Health, Center for Health Facilities Regulation
1
Nursing Facility Required Reporting
Certified Facilities
Reporting Facility:
Date of Report:
Reported by:
Title:
Contact Number:
Report any suspicion of a crime committed against a resident that results in serious bodily harm within two (2) hours to Law Enforcement and to
the Department via phone (401) 222-5200. All other suspicions of a crime against a resident that does not result in serious bodily harm must be
reported to Law Enforcement and the Department within 24 hours (as defined in Section 1150B of the Social Security Act, as established by section
6703(b)(3) of the Patient Protection and Affordable Care Act, 2010).
Must be reported as defined below:
Abuse, Neglect, Mistreatment & Injuries of Unknown Source:
*Resident to Resident Abuse
Report all alleged violations involving abuse, neglect, exploitation or mistreatment, including
*Staff to Resident(s) Abuse
injuries of unknown source and misappropriation of resident property; immediately, but not later
than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or
*Neglect
result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do
not involve abuse and do not result in serious bodily injury (in accordance with 42 CFR
*Misappropriation / Exploitation
§483.12(c)(1))
*Injuries of Unknown Source
Accidents /Incidents/ Death:
Must be reported within 24 hours or by the next business day, unless otherwise indicated. Please select the most
appropriate:
Accident / incident resulting in hospital admission
Death within 24 hours of admission or prior to physical exam
Accident / incident resulting in death in the facility
Elopement: (Only required if police were notified)
*Accident or incident resulting in death in the
Unscheduled implementation of fire/evacuation/disaster plan.
hospital following an accident
Report immediately via phone (401) 222-5200, then fax this form within
three (3) business days.
*Indicates 5-Day Facility Investigation Report must be faxed to the Department within five (5) business days.
Resident(s) Information:
Last Name:
First:
DOB
Female
Male
Room #
Last Name:
First:
DOB
Female
Male
Room #
Alleged Perpetrator(s) Information (if applicable):
Last Name:
First:
Resident
Non-resident
Staff
Last Name:
First:
Resident
Non-resident
Staff
Has Victim(s) and/or Abuser(s) been involved in previous reportable incidents?
If yes, please describe.
Incident Information:
Date of Incident:
Time:
Location of Incident:
Witness(s):
No
Yes
(Provide names)
Description of incident and immediate action taken to ensure safety of resident(s). Include any resident(s) injury.
CONTINUE ON ADDITIONAL PAGES AS NEEDED
FAX to: Facilities Regulation: (401) 222-3650 or (401) 222-3999 and RI LTC Ombudsman: (401) 785-3391
1
Reports may be called in immediately to DOH-222-5200 and the RILTCOO-785-3340 with follow-up faxes of this form by the next business day.
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