"Nursing Facility Required Reporting - Licensed-Only Facilities" - Rhode Island

This "Nursing Facility Required Reporting - Licensed-Only 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 - Licensed-Only Facilities" - Rhode Island

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CHFR 10-3-18
Department of Health, Center for Health Facilities Regulation
1
Nursing Facility Required Reporting
Licensed-Only Facilities
Reporting Facility:
Date of Report:
Reported by:
Title:
Contact Number:
Abuse, Neglect, & Mistreatment:
Must be reported within 24 hours, or by the next business day (as defined in §23-17.8- 2). Please select the
most appropriate:
*Resident to Resident Abuse
If reported by a person other than a physician, certified registered nurse practitioner, or
physician assistant that a resident has been harmed, then the resident must be examined by
*Staff to Resident(s) Abuse
a licensed physician, certified registered nurse practitioner, or physician assistant and a
*Injury of Unknown Origin
preliminary report must be made to the Department within (48) hours after the examination,
*Neglect
and a follow-up written report within five (5) days after examination (as defined in Section
23-17.8- 3.1)
*Misappropriation /Exploitation
Accidents /Incidents/ Death:
Must be reported within 24 hours or by the next business day, unless otherwise indicated. Please select the most
appropriate:
Death within 24 hours of admission or prior to physical
Accident or incident resulting in hospital admission
exam
Accident or incident resulting in death in the facility
Elopement: (Only required if police were notified)
*Accident or incident resulting in death in the hospital
Unscheduled implementation of fire/evacuation/disaster
following an accident
plan
.
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:
Room #
Female
Male
Last Name:
First:
DOB:
Room #
Female
Male
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
Licensed-Only Facilities
Reporting Facility:
Date of Report:
Reported by:
Title:
Contact Number:
Abuse, Neglect, & Mistreatment:
Must be reported within 24 hours, or by the next business day (as defined in §23-17.8- 2). Please select the
most appropriate:
*Resident to Resident Abuse
If reported by a person other than a physician, certified registered nurse practitioner, or
physician assistant that a resident has been harmed, then the resident must be examined by
*Staff to Resident(s) Abuse
a licensed physician, certified registered nurse practitioner, or physician assistant and a
*Injury of Unknown Origin
preliminary report must be made to the Department within (48) hours after the examination,
*Neglect
and a follow-up written report within five (5) days after examination (as defined in Section
23-17.8- 3.1)
*Misappropriation /Exploitation
Accidents /Incidents/ Death:
Must be reported within 24 hours or by the next business day, unless otherwise indicated. Please select the most
appropriate:
Death within 24 hours of admission or prior to physical
Accident or incident resulting in hospital admission
exam
Accident or incident resulting in death in the facility
Elopement: (Only required if police were notified)
*Accident or incident resulting in death in the hospital
Unscheduled implementation of fire/evacuation/disaster
following an accident
plan
.
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:
Room #
Female
Male
Last Name:
First:
DOB:
Room #
Female
Male
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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