Free Caregiver Misconduct Incident Report-F-62447 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62447 (Rev. 07/08)

STATE OF WISCONSIN HFS 13.05(3)(a), Wis. Admin. Code Page 1 of 8

CAREGIVER MISCONDUCT INCIDENT REPORT
GENERAL INSTRUCTIONS
Use this form to report incidents of alleged caregiver misconduct (client abuse or neglect or misappropriation of client property) and injuries of unknown source. The Department reviews this report to determine whether further investigation of the incident is warranted. So that the Department may make this determination, please complete the Caregiver Misconduct Incident Report form in its entirety. Use the following information as guidance when completing the incident Report. I. ENTITY INFORMATION (Page 3) The entity or facility named is the entity responsible for the care of the affected client. The Department will send all responses regarding the report to the entity reporter and address listed in this section. ENTITY TYPE CODES Code 34 40 61 63 75 82 83 88 89 Entity Type Emergency Mental Health Service Programs Mental Health Day Treatment Services for Children Outpatient Community Mental Health/Developmental Disabilities Community Support Programs Community Substance Abuse Services (CSAS) Certified Adult Family Homes Community Based Residential Facilities Licensed Adult Family Homes Resident Care Apartment Complexes Code 113 124 127 131 132 133 134 000 Entity Type First responder/defibrillation Hospitals Rural Medical Centers Hospices Nursing Homes Home Health Agencies Facilities for Persons with Developmental Disabilities Other (Specify.)

II. SUMMARY OF INCIDENT (Pages 3 and 4) · Indicate when the incident occurred. Include the month, day, year, and time of the incident (e.g., 08/25/2003, 10:30 AM). If you do not know the exact day, provide an approximate date (e.g., the week of March 1, the month of March, between March 1 and April 15). If you give approximate dates, explain how you determined the dates. · Briefly describe the incident. Summarize the incident in the space provided, even if more details or documents are attached. · Describe the effect of the incident upon the client or the client's reaction to the incident. If a client has been physically injured, describe the injury, the size of the bruise, etc. A photograph of the injury is very helpful. If photographs are taken, identify when the photos were taken, how many were taken and by whom. Describe any indication or expressions of pain, anger, frustration, humiliation, fear, etc. by the client during or after the incident. · Explain what the entity did, upon learning of the incident, to protect the client(s) from further potential caregiver misconduct. Describe the steps that the entity took to protect the client(s) from subsequent potential episodes of caregiver misconduct while a determination on the matter is pending. Indicate the accused person's current employment status and date of any employment action after the alleged incident. NOTE: The entity is not required to terminate the employment of an accused person to meet client protection requirements.

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Check the specific location where the incident happened. If the incident happened at a location other than the entity, indicate the specific address of that location.

III. AFFECTED CLIENT INFORMATION (Page 4) A client is a person who receives care of treatment services from an entity. Include the affected client's name, date of birth, gender, address, and telephone number. If the affected client has been adjudicated incompetent, is under age 18, or has an authorized Power of Attorney for Health Care, include the name, address, and telephone number of the parent, guardian, or legal representative. IV. ACCUSED PERSON INFORMATION (Page 4) Include information about an accused person who meets the definition of a caregiver or non client resident. A caregiver is a person who meets all of the following criteria: (1) is employed by or is under contract with an entity, (2) has regular, direct contact with the entity's clients or the personal property of the clients, and (3) is under the entity's control. Caregivers also include the owners or administrators of entities (whether or not they have regular, direct contact with clients) or a board member or corporate officer who has regular, direct contact with the clients served. A non client resident is a person 12 years of age or older who is not a client but who resides at the entity and is expected to have regular, direct contact with clients. Include the accused person's name (if known), social security number, position or title at the time of the incident, date of birth, gender, current home address, and home telephone number. Entities must inform the accused person that a report regarding the incident is being filed with the appropriate authority. If the accused person is currently employed by an entity other than the reporting entity, include the name, address, and telephone number of the current employer. If the accused person is under age 18, provide the name, address, and telephone number of a parent or guardian. If there is more than one accused person, complete this section for each person. V. LAW ENFORCEMENT INVOLVEMENT (Page 5) Check if law enforcement was contacted or is involved. Indicate the officer's name, department, address, telephone number, and---if available---the case number. Attach a copy of the law enforcement incident report, if available. VI. PERSONS WITH SPECIFIC KNOWLEDGE OF THE INCIDENT (Page 5) Include all persons with specific knowledge of the incident. Include the person's name, gender, address, and telephone number. Check whether the person is an entity employee. Include the person's position at the entity or relationship to the affected client. Attach additional pages, as necessary.

F-62447 (Rev. 10-07) VII. DESCRIBE BELOW OR ATTACH A COPY OF THE ENTITY'S INVESTIGATIVE RECORDS CONCERNING THE INCIDENT (Page 6) Provide all relevant information found during the entity's internal investigation, including the following: · STAFF INFORMATION Accused individual's personnel records, including but not limited to training records, disciplinary records, time cards or sheets for the period during which or date(s) the incident occurred. Witness time cards or sheets for the period or date(s) the incident occurred. Staff schedule, roster, or assignment sheets for the time period or date(s) the incident occurred. Statements from the accused individual and witnesses relating to the incident. Sign-off sheets indicating completion of cares pertinent to the incident. ENTITY INFORMATION Entity's policies and procedures related to the incident. Photographs and diagram or illustration of the scene where the incident occurred with relevant information included, i.e., locations of witnesses, client, and pertinent objects at the time of the incident. · · · · · ·

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CLIENT INFORMATION Client's pertinent medical records, including but not limited to the client's plan of care or treatment plan at the time of the incident. Ambulance run report, if applicable. Any relevant hospital admission and discharge documents. Photographs of visible injuries or affected property. Financial account statements, including account numbers and balance information. Statements about the incident. LAW ENFORCEMENT INFORMATION Law enforcement officer's narrative reports. Photographs. OTHER INFORMATION Any other records that may apply.

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VIII. PERSON PREPARING THIS REPORT (Page 6) Provide the name, position or title, and telephone number of the person preparing this report. The person preparing this report must sign and date this form in the space provided. IX. WRITTEN STATEMENT (Pages 6 and 7) · Ask the affected client, the accused person, and all other persons with information about the incident to provide written statements. · If the entity uses its own forms to obtain written statements about the incident, the entity may attach those forms to the Incident Report. If the entity attaches its own written statements to the report form, the facility should ensure that each person completing a written statement provides the identifying information requested on the report form and signs the statement. · The entity is advised to follow up on written statements by asking probing questions to gather as much detail as possible, including what happened, how the incident happened, when it happened, where it happened, reactions at the time of the incident, and other witnesses who may have been present. It is suggested that the entity use the FOLLOW UP QUESTIONS (Page 8) following the written statement form as a guide when questioning the accused person.

MANDATORY REPORTING TIMELINES
FEDERALLY CERTIFIED NURSING HOMES AND FEDERALLY CERTIFIED INTERMEDIATE CARE FACILITIES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES Upon the completion of the entity's internal investigation of the incident, send the completed form, any available documentation, and the results of your investigation within 5 WORKING days (Monday ­ Friday, excluding legal holidays) of the date the entity knew or should have known of the incident. ALL OTHER ENTITIES Upon the completion of the entity's internal investigation of the incident, send the completed form, any available documentation, and the results of your investigation within 7 CALENDAR days of the date the entity knew or should have known of the incident.

MAILING INSTRUCTIONS
NOTE: All complaints regarding both credentialed staff (e.g., RN, LPN, MD) and non credentialed staff (e.g., nurse aides, personal care workers, housekeepers) will be tracked by the Department of Health and Family Services, Division of Quality Assurance (DQA). DQA will refer complaints that involve credentialed staff to the Department of Regulation and Licensing for investigation. Send the completed form and any supporting documentation to the following address:

Department of Health Services Division of Quality Assurance Office of Caregiver Quality P.O. Box 2969 Madison, WI 53701-2969 DIRECT QUESTIONS REGARDING THIS FORM TO (608) 261-8319.

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62447 (Rev. 07/08)

STATE OF WISCONSIN 3 HFS 13.05(3)(a), Wis. Admin. Code Page 3 of 8

CAREGIVER MISCONDUCT INCIDENT REPORT
Completion of this form is required by HFS 13.05(3)(a), Wis. Admin.Code. Failure to file a complete and accurate report of an incident of alleged caregiver misconduct as required may subject the entity to forfeiture or other sanctions specified by the Department under HFS 13.05(3)(e), Wis. Admin. Code, and may delay the investigation process. Personal information will be used to investigate the reported incident and the results of the investigation may be shared with other authorized investigative agencies. Disclosure of the caregiver's social security number is voluntary; however, the Department uses that number for the purpose of identification and it is used to place a substantiated finding of abuse, neglect, or misappropriation of property on the Caregiver Misconduct Registry in the name of the correct person.

This report form must be completed in its entirety. Additional information may be attached. TYPE OR PRINT NEATLY IN BLACK INK. I. ENTITY INFORMATION
Name ­ Entity or Facility Street Address Telephone Number County Federal Provider or Certification No.

City

State

Zip Code

State License, Approval, or Registration No.

Name ­ Administrator

Entity Type Code (See instructions.)

II. 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)

BRIEFLY DESCRIBE THE INCIDENT in the space provided below. Summarize the incident here even if additional documentation is attached.

DESCRIBE THE EFFECT that the incident had on the client and the client's reaction to the incident and the reaction of other clients who witnessed the incident.

F-62447 (Rev. 07/08)

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EXPLAIN what steps the entity took upon learning of the incident to protect the client(s) from further potential caregiver misconduct.

CHECK the specific location where the incident happened.
At your entity During transport Another location ­ EXPLAIN.

III. AFFECTED CLIENT INFORMATION
Name - Client Address Date of Birth (mm/dd/ccyy) Gender Male Female

Telephone Number

City

State

Zip Code

If the client is adjudicated incompetent or under 18, or has an authorized Power of Attorney for Health Care, include the name, address, and telephone number of parent, guardian, or legal representative.
Name - Parent, Guardian, or Power of Attorney Telephone Number

Address

City

State

Zip Code

IV. ACCUSED PERSON INFORMATION
Name - Accused Person Accused Person's Position or Title (at the time of the incident) Gender Male Non Credentialed Staff Credentialed Staff Home Street Address Home Telephone Number Female Social Security Number Date of Birth (mm/dd/ccyy)

List Any Known Credential Held by the Accused at Time of the Incident, e.g., RN, LPN, Social Worker, Security Guard, Professional Counselor.

City

State

Zip Code

NOTE: If employer is other than the reporting entity, provide information about accused person's current employer.
Name ­ Employer Street Address City Gender Male Telephone Number Female State Zip Code

NOTE: If accused person is under 18, provide parent(s) or guardian information.
Name(s) - Parent or Guardian Street Address City Gender Male Female State Zip Code Telephone Number

F-62447 (Rev. 07/08)

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V. LAW ENFORCEMENT INVOLVEMENT Was law enforcement contacted or involved?
No Yes If yes, fill in the information below. Attach a copy of the law enforcement incident report, if available.
Department Name - Officer (if available)

Street Address

Case Number (if available)

City

State

Zip Code

Telephone Number

VI. PERSONS WITH SPECIFIC KNOWLEDGE OF THE INCIDENT (If more space is necessary, attach additional pages.)
Name - Person Who REPORTED Incident to the Entity Street Address Gender Male Female Telephone Number

City

State

Zip Code

Is this Person an ENTITY EMPLOYEE? Yes No

Reporting Person's Position in the Entity or Relationship to the Client

Name - Person With Information About the Incident Address

Gender Male Female Telephone Number

City

State

Zip Code

Is this Person an ENTITY EMPLOYEE? Yes No

Position in the Entity or Relationship to the Client

Name - Person With Information About the Incident Address

Gender Male Female Telephone Number

City

State

Zip Code

Is this Person an ENTITY EMPLOYEE? Yes No

Position in the Entity or Relationship to the Client

Name - Person with Information About the Incident Address

Gender Male Female Telephone Number

City

State

Zip Code

Is this Person an ENTITY EMPLOYEE? Yes No

Position in the Entity or Relationship to the Client

Name - Person with Information About the Incident Address

Gender Male Female Telephone Number

City

State

Zip Code

Is this Person an ENTITY EMPLOYEE? Yes No

Position in the Entity or Relationship to the Client

F-62447 (Rev. 07/08)

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VII. DESCRIBE BELOW OR ATTACH A COPY OF THE ENTITY'S INVESTIGATIVE RECORDS CONCERNING THE INCIDENT.
Documentation of the entity's investigation is attached. Check appropriate box(es) for attached entity investigation records.

VIII. PERSON PREPARING THIS REPORT (TYPE or PRINT neatly in BLACK INK.)
Name Street Address Are you an ENTITY EMPLOYEE? Yes No Telephone Number Position in the Entity or Relationship to the Client

City

State

Zip Code

SIGNATURE - Person Preparing This Report

Date Signed (mm/dd/ccyy)

IX. WRITTEN STATEMENT
Use this page to collect written statements from the accused person, affected client, and witnesses regarding incidents of alleged caregiver misconduct (client abuse or neglect or misappropriation of client property). Make additional copies of this page as necessary. Completion of this form is voluntary. It is suggested that entities ask the questions on the following page to obtain additional information and detail about reported incidents. Please record all responses given. Entities may use their own forms; however, any written statement must be attached and submitted with the Caregiver Misconduct Incident Report form (F-62447).

Section 1 (To be completed by entity)
Brief Description of Alleged Incident (e.g., "Marion R's broken arm," "the theft of Marion R's credit card," "Marion R's fall.")

Section 2 (To be completed by accused person, affected client, or witness)
Full Name (Last, First, Middle Initial) Street Address Home Telephone Number Work Telephone Number

City

State

Zip Code

Position / Title or Relationship to the Client

F-62447 (Rev. 07/08)

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Section 3 (To be completed by accused individual, affected client, or witness)
Provide as much information as you know about the incident described above. Tell what you know about the incident in detail. Use additional pages as needed. Check if additional pages are included.

SIGNATURE - Accused Individual, Affected Client, or Witness

Date Signed (mm/dd/ccyy)

F-62447 (Rev. 07/08)

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FOLLOW UP QUESTIONS TO BE ASKED BY THE ENTITY
It is suggested that entities ask the following questions to obtain additional, detailed information about reported incidents. Please record all responses in the space provided. Attach additional pages, information, documentation, diagrams, photographs, or other evidence as appropriate. Check if additional pages are included.

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How do you know about the above incident? Did you do it? Did it happen to you? Did you see it? Did another person tell you of it? If so, who? Time and date of the incident. When did it happen? When did you first learn about it?

Location. (Where did the incident occur? Where were you when it happened? If others were present, who and where were the others? Where were you when you learned about it or saw it? Describe the location. Attach a diagram.) Was anyone else present when it happened, you learned about it, or when you saw it? If so, who? Where was each person?

Did you tell anyone about the incident? If so, what did you tell them, who did you tell and when did you tell them? What did the person say, if anything? Were you or a client harmed in any way (physically or sexually, emotionally or mentally, or financially) or could you or a client have been harmed? If so, describe the harm or potential harm. Were others harmed in any way? If so, identify the person who was harmed and describe the harm.

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Describe your or the client's actions or reactions during the incident including statements made, changes in demeanor, or other indications of pain, fear, sadness, anger, humiliation, etc. Describe the actions or reactions of others who observed or were involved in the incident.

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For Affected Clients: Did you tell anyone about what happened to you? If so, who did you tell and when and where did you tell them?

For Other Witnesses: Is or was the client able to report or talk about the incident?

If so, did the client say anything to you? If so, what? Describe the way the client acted when telling you about the incident.

To your knowledge, did the client tell anyone else? If so, who and when?

Are there others who know or may know about the incident? If so, who are they and why do you think they have information about the incident? Do you have or are you aware of any evidence, documentation or information that may be relevant to the incident? (Examples: photos, diagrams, maps, receipts, video tapes, audio tapes, medical records, care plans, financial transaction records, etc.) If so, what is it and where is it?
Check if items or documents are attached. Check if a photocopy of an item or document is attached. Check if an item or document is being retained by the entity; describe where and how it is being stored pending the outcome of this investigation.

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Additional Information

Name - Person Interviewed

Name - Person Conducting the Interview

Date (mm/dd/ccyy)