Free Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, F-62617 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62617 (Rev. 07/08) Entity Report Number

STATE OF WISCONSIN

CG Report Number

ALLEGED NURSING HOME RESIDENT MISTREATMENT, NEGLECT, AND ABUSE REPORT
· Completion of this form is necessary to meet the requirements in Federal regulation 42 CFR 483.13(c)(2). Nursing homes are required to report incidents of alleged mistreatment, neglect and abuse of nursing home residents (including injuries of unknown source), and misappropriation of resident property to the Division of Quality Assurance (DQA), the state survey and certification agency. Nursing homes must ensure that all alleged incidents be reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures, which include reporting the incident to DQA. 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. Questions about completion of this form may be directed to 608-261-8319. NOTE: Upon completion of the facility's investigation, attach a copy of this form to the completed Caregiver Misconduct Incident Report, F-62447, and submit to the address listed in the instructions for F-62447. Submit this completed form to DQA via: E-mail: [email protected] or FAX: (608) 264-6340

·

· · ·

· TYPE OR PRINT NEATLY IN BLACK INK. ENTITY INFORMATION
Name - Entity or Facility Street Address Telephone Number County Federal Provider or Certification Number

City

State

Zip Code

State License, Approval, or Registration Number

Name - Administrator

SUMMARY OF INCIDENT
INDICATE WHEN THE INCIDENT OCCURRED. If the exact date and time are unknown, make a reasonable estimate and indicate that the date and time are estimated. Include the date the incident was discovered, if other than the date the incident occurred.
Date Occurred (mm/dd/ccyy) Time Occurred Date Discovered (mm/dd/ccyy)

a.m. p.m.

BRIEF SUMMARY OF INCIDENT

PERSON PREPARING THIS REPORT
Name Title Date Report Completed