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LONG TERM CARE FAX REPORTING
OF INCIDENTS AND ABUSE

GENERAL INSTRUCTIONS:

These instructions apply to reporting all incidents, and suspected abuse, neglect, mistreatment and misappropriation of resident property under the Patient Abuse Law.

Complete a separate blank form for each occurrence following the instructions below.

Use the attached tables to enter a description for those items that are marked “see table.”

Submit your completed report by fax to the Department immediately for (1) suspected abuse, neglect or misappropriation; (2) epidemic disease; (3) fires; and (4) death resulting from incidents. Notify the Department immediately by phone at 617-753-8150 of any deaths resulting from incidents, medication errors, abuse or neglect; and full or partial evacuation of the facility for any reason. Submit other completed reports within seven days of the date of the occurrence of an incident resulting in serious harm.

Fax your completed report to the Department at 617-753-8165.

LINE-BY LINE INSTRUCTIONS

PAGE 1 OF REPORT FORM:

FROM: Please provide the name and address of the facility making the report.

DATE OF REPORT: Enter the date that you are submitting your report to the Department.

GENERAL INFORMATION: Please indicate your name and title, as the person preparing this report, a phone number at which we can contact you if we need additional information, and the date and time of the occurrence. If you are not able to determine when the event occurred, state “unknown”.

RESIDENT INFORMATION: Please provide information here regarding the resident involved. The information reported here should reflect the resident’s condition prior to the occurrence. If more than one resident was injured, or one resident has injured another resident, provide additional resident information under the narrative portion of the report or on an additional page. Please indicate:

NAME: The resident’s first and last name.

AGE; SEX; ADMISSION DATE: Enter each for the named resident.

AMBULATORY STATUS: Select the term from Table #1, “Ambulatory Status”, that most closely describes the resident’s ability to walk.

LINE BY LINE INSTRUCTIONS - CONTINUED

ADL STATUS: Activities of Daily Living (ADLs) such as eating, dressing or personal grooming. Select the term from Table #2, “Resident ADL Status”, that most closely describes the resident’s ability to perform these functions.

COGNITIVE LEVEL: Select the term from Table #3, “Resident Cognitive Status”, that best describes the resident’s cognitive status at the time of the occurrence.

MENTALLY RETARDED/DEVELOPMENTALLY DISABLED: Indicate whether or not the
resident is mentally retarded or developmentally disabled. If the resident is either, indicate the name of the Service Coordinator (mentally retarded) or Case Manager (developmentally disabled) assigned to the patient, if known.

REPORT DETAIL:

OCCURRENCE TYPE: Select the term from Table #4, “Occurrence Type”, that best describes the occurrence you are reporting. You may select “Other” and describe what happened in one or two words if none of the examples listed are applicable to your report.

TYPE OF HARM: Select the term from Table #5, “Type of Harm”, that best describes the harm or injury that resulted from the occurrence. You may select “Other” and describe what happened in one or two words if none of the examples listed are applicable to your report. Note that harm includes psychological injury as well as physical harm, and SHOULD NOT BE DESCRIBED AS “NONE” SIMPLY BECAUSE THERE WAS NO PHYSICAL HARM.

BODY PART AFFECTED: Use terms such as “arm”, “foot”, etc.; indicate left or right when it applies.

RESIDENT’S ACTIVITY AT TIME OF OCCURRENCE: Select the term from Table #6, “Resident’s Activity”, that best describes the resident’s activity at the time of the occurrence. You may select “Other” and describe what happened in one or two words if none of the examples listed are applicable to your report.

PLACE OF OCCURRENCE: Specify where the event occurred. Examples would include: “resident’s room”, “dining room”, “shower room”, or any other short phrase that specifies the type of setting in which the occurrence took place.

WHAT EQUIPMENT, IF ANY, WAS BEING USED AT TIME OF OCCURRENCE: Specify if any equipment was in use, such as “Hoyer lift”, or “walker”.

ANY SAFETY PRECAUTIONS IN PLACE: Check the “yes” or “no”. If “yes”, describe the precautions that were in place.

LINE BY LINE INSTRUCTIONS - CONTINUED

PAGE 2 OF REPORT FORM:

NARRATIVE: Describe fully what occurred. Indicate who, what, when, where, why and how what is being reported occurred. Include information on how any person injured was treated. If there were any unusual circumstances involved, describe these fully.

CORRECTIVE MEASURES NARRATIVE: Describe what actions have been taken in response to the occurrence. Note that in the case of abuse, neglect, mistreatment and misappropriation, or injuries of an unknown cause in Medicaid and Medicare certified facilities, federal regulations require that you have evidence that an investigation occurred and the resident was protected from future injury.

NOTIFICATION: Indicate whether or not the resident’s family and physician, and police were notified. Provide the name of the physician notified. Indicate whether any person injured was brought to the hospital, and if so, the hospital they were brought to.

STAFF PERSON IN CHARGE OF FACILITY AT TIME OF OCCURRENCE: Indicate who was in present and charge at the facility (not on the unit) when the occurrence reported happened.

WITNESS INFORMATION: List the name and title for individuals who saw or heard what occurred. Indicate if any of witnesses were directly involved in what occurred. Other residents, visitors and volunteers should be listed as witnesses if they have direct knowledge of what occurred.

ACCUSED INFORMATION: When reporting suspected abuse, neglect or misappropriation, indicate the name of the accused, a phone number at which the accused can be contacted, if the accused is a nurse, nurse aide or other licensed professional please indicate the individual’s license or registration number. Check the appropriate block if you are not reporting abuse, or the identity of the person(s) suspected of abuse, neglect or misappropriation of a resident’s money or belongings is unknown. If more than one individual is suspected, indicate on an additional sheet the other individual’s names, a phone number at which they may be contacted, and if any person was acting as a nurse aide.

LINE BY LINE INSTRUCTIONS - CONTINUED

REPORTING TABLES:

Table #1: Ambulatory Status: Table #2: Resident ADL Status:

Independent Independent
Supervised Supervised
Dependent/Assist Dependent
Wheels Self Unknown
Wheelchair Other
Bedfast
Unknown

Table #3: Resident’s Cognitive Status: Table #4: Occurrence Type:

Alert/Oriented Fall
Dementia Abuse
Mentally Retarded/Developmentally Disabled Neglect
Confused Misappropriation
Alzheimer’s Resident to Resident
Comatose Injury of Unknown Origin
Unknown Epidemic Disease
Other Food Poisoning
Death
Table #5: Type of Harm: Suicide
Missing Person
Fracture Criminal Act
Laceration Fire
Bruise/Hematoma Pending Strike
Reddened Area Choking
Dislocation Other (Describe)
Burn Equipment Malfunction
Unwelcome Sexual Contact/Advance
Emotional Harm/Upset Table #6: Resident’s Activity
Care Not Provided
Quality of Care Ambulating
Decline in Condition Toileting
Infection Transfer/Assist
Confinement Getting Out of Bed
Property Getting Up From Chair
Funds Reaching
Death Standing/Sitting Still
No Harm Crowded Area
Other(Describe) Unknown
Unknown Other(Describe)
LONG TERM CARE FAX REPORT FORM

TO: INTAKE STAFF
DEPARTMENT OF PUBLIC HEALTH, DIVISION OF HEALTH CARE QUALITY
FAX NUMBER (617) 753-8165

FROM: Facility Name: __________________________________________
Address (Street): __________________________________________
Address (City/Town) __________________________________________

DATE OF REPORT: _______________ NUMBER OF PAGES: ____________

GENERAL INFORMATION:
Report prepared by: __________________________________________
Title: __________________________________________
Phone Number: (________)_________-___________Ext:_________
Date of Occurrence: Month____________ Date_________ Year________
Time of Occurrence: ________________________ am______ pm_______

RESIDENT INFORMATION:
Name: First_________________Last__________________
Age: ______________
Sex: Male _________ Female __________
Admission Date: Month___________ Date__________ Year________
Ambulatory Status (See table #1):__________________________________
ADL Status (See table #2): __________________________________
Cognitive Level (See table #3):________________________________
Mentally Retarded/Developmentally Disabled: ____ Yes ____No
If yes, Service Coordinator or Case Manager (if known): _________________________

REPORT DETAIL:
Occurrence Type (See table #4):__________________________________
Type of Harm (See table #5):__________________________________
Body Part Affected: _____________________ L:____ R: ____
Resident’s activity at time of
occurrence (See table #6): __________________________________
Place of Occurrence: __________________________________
What equipment, if any, was being
used at time of occurrence? _________________________________
Any safety precautions in place?Yes________ No_________
If yes, describe what preventive measures were in place:

[Form continues to page 2.]FACILITY NAME: _____________________ DATE OF OCCURRENCE: _____________

NARRATIVE: (Please address the following: What happened? What factors contributed to the occurrence? Any relevant information which establishes cause? Have there been similar incidents in the past? How were the injuries treated? [Attach additional pages as needed.] )

Were there any unusual circumstances involved? Yes________ No__________ If yes, please describe. [Attach additional pages as needed.]

CORRECTIVE MEASURES NARRATIVE: (Please address the following: Was there an internal investigation: Yes________ No__________. If No - why? If yes - What are the investigation findings? What action was taken with regard to: Resident?; Staff?; Facility practice? What is the resident's current status? What corrective action taken regarding equipment involved, if applicable? [Attach additional pages as needed.] )

NOTIFICATION:
Was family notified: Yes__________ No_____________
Was MD notified: Yes__________ No_____________
Name of MD if notified: _________________________________________
Was resident brought to hospital: Yes_____(Hospital:_______________) No _______
Were police notified: Yes__________ No_____________

STAFF PERSON IN CHARGE OF FACILITY AT TIME OF OCCURRENCE:
Name: Title: Directly Involved:
_____________________________________________________YES_____NO_______

WITNESS INFORMATION: (Check here if unwitnessed: ____________)
Name: Title: Directly Involved:
_____________________________________________________YES_____NO_______
_____________________________________________________YES_____NO_______

ACCUSED INFORMATION: (Check here if unknown or not applicable: _________)
Name: Telephone #:
________________________________(_____)_____-_______ CNA ___; RN/LPN ____
If CNA, RN/LPN or other licensed individual, indicate license #:________________
FILENAME=FAX LTC 9-2002.doc