Incident Report - Page 714

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Suppose you work at Prairie Hills Nursing Home (license number 05-5990), located at 341 South Hill Road in Ventura, CA 93003. It is located in Ventura County. This morning you were helping a resident, Ceci Jones, get dressed for breakfast. You noticed a long, narrow bruise on her upper arm. You ask her about it and she says the man who drives the transport van grabbed her arm yesterday after she accidentally pressed her cane into his foot.

Ceci says she tried to apologize to the driver, but he just gripped her arm tightly and made a terrible face at her. She says it hurt, but she didn't tell anyone because she was scared. She also says she doesn't want to ride in the van to the store tomorrow because she is afraid he is still mad and may hurt her again. You reassure Ceci that she is safe and then report the bruise and Ceci's story to your supervisor. You are instructed to enter the information you know into the incident reporting system.

Fill out the incident report form shown here with the information provided.

Sun View Medical

Mandatory Reporting Requirements for Nursing Homes

Completion of this form is required to meet the requirements in Federal regulation 42 CRF 483.13(c)(2). Nursing homes must immediately report incidents of alleged mistreatment, abuse and neglect of residents (including injuries of unknown source), and misappropriation of resident property to the Division of Quality Assurance (DQA), the state survey and certification agency. The Centers for Medicaid and Medicare Services (CMS) defines "immediately" to be as soon as possible but not to exceed 24 hours after discovery of the incident. Failure to provide the following information to DQA within 24 hours of discovering an incident may result in the issuance of a statement of deficiency.

Because the federal definitions do not specify that an incident has to involve a caregiver, nursing homes are required to submit allegations of mistreatment by anyone, including residents. Note that the federal definition of abuse indicates that the act needs to be "willful" and that it needs to have resulted in physical or psychosocial harm to the resident or would be expected to have caused harm to a "reasonable person" if the resident cannot provide a response.

For a definition of "willful," please refer to the interpretive guidelines at F323 where, under ResidenttoResident Altercations, it notes, "An incident involving a resident who willfully inflicts injury upon other resident should be reviewed as abuse under the guidance for 42 CFR 483.13(b) at F223. 'Willful' means that the individual intended the action itself that he/she knew or should have known could cause physical harm, pain or mental anguish. Even though a resident may have a cognitive impairment, he/she could still commit a willful act."

Questions about this completed form may be directed to the DQA Office of Caregiver Quality. To print a copy of this report, click on your browser's print button before you click on the Send button below. Upon completion of the facility's investigation and within 5 days of the date discovered, the nursing home must submit an Incident Report F62447 with supporting documentation to the DQA Office of Caregiver Quality.

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