AGING AND DISABILITY SERVICES ADMINISTRATION

APPENDIX F – NURSING HOMES
STATE HOTLINE QUESTIONS (1-800-562-6078)
October 2003

To make an official facility report, listen to the main message and then press “2”. If you wish to bypass the next menu, press the number that represents the type of incident you will be reporting.

#	TYPE OF INCIDENT
1	Follow-up Call
2	Resident-to-Resident Incident
3	Staff-to-Resident Incident
4	Injury of Unknown Source
5	Resident Fall
6	Exploitation/Misappropriation of Resident Property
7	Other Types of Resident Incidents
8	Medication Error

The following standard information is required by facilities making reports to the state hotline:

ALL TYPES OF INCIDENTS:

1. Caller’s first and last name:
2. Name of the facility followed by phone number;
3. The name of the resident(s) who is/are involved in the incident;
4. Identify if the doctor and responsible parties were notified of the incident
5. The resident’s diagnosis
6. The resident’s mental status
7. The resident’s ambulatory and transfer status, or if wheelchair bound, identify if the resident self-propels and if he/she was using an assistance device
8. The date and time of the allegation, incident, or injury, or the date and time when the allegation, incident or injury was first discovered.
9. Identify if the care plan has changed.

In addition to the above questions, be prepared to provide the following information when calling to report:

FOLLOW-UP CALL – Select 1:

1. Identify the date of the initial report;
2. Identify the conclusion of the investigation;
3. Identify measures put in place to prevent a reoccurrence.

A RESIDENT-TO-RESIDENT INCIDENT – Select 2:

1. Describe the incident and any injuries;
2. Identify if the incident was sexual in nature;
3. Identify if it was witnessed and if so, by whom.
4. Identify if there was evidence of psychological harm.
5. Identify if the incident is isolated or a pattern;
6. Describe the plan to prevent further incidents.

ALLEGATION OF STAFF TO RESIDENT ABUSE OR NEGLECT – Select 3:

1. Describe the alleged incident, and any injuries;
2. Identify if the incident was sexual in nature;
3. Identify if it was witnessed and if so, by whom.
4. Identify if there was evidence of psychological harm.
5. Identify the correct spelling and name of the employee(s) including their middle initial;
6. Identify the employee’s title and if a nursing assistant, if he or she is certified;
7. Identify the employee’s date of hire and date of birth;
8. Identify the employee’s social security number;
9. Describe the action, if any, taken with the employee, (if suspended or terminated, identify the dates);
10. Identify if the employee has had previous warnings or incidents at your facility;
11. Describe the measures taken to protect the resident during the investigation;
12. Describe measures taken to prevent reoccurrences of the incident.

AN INJURY OF UNKNOWN SOURCE – Select 4:

1. Describe the injury, location on the body, the size, and if a bruise, describe the color;
2. Identify if the injury was sexual in nature;
3. Identify if treatment was required and if further treatment will be needed.

RESIDENT FALL – Select 5:

1. Describe other falls within the last 12 months;
2. Identify witnesses;
3. If staff involved, state their name and explain the circumstances.
4. Identify if the care plan was followed at the time of the fall;
5. Identify if motion alarms were in use.
6. Identify the action taken to prevent reoccurrences.

EXPLOITATION OR MISAPPROPRIATION OF RESIDENT PROPERTY – Select 6:

1. Describe the details of the exploitation or misappropriation of property including the dollar amount;
2. Identity if local law enforcement has been notified, if so, identify the case number;
3. Identify the alleged perpetrator and identify the person’s title or relationship to the resident;
4. If an employee is involved, identify their name including the middle initial, title, date of hire, date of birth and social security number;
5. Identify the action taken to prevent reoccurrences.

OTHER TYPES OF RESIDENT INCIDENTS – Select 7:

1. Describe the injury, location on the body, the size, and if a bruise, describe the color;
2. Identify if the injury was sexual in nature;
3. Identify if treatment was required and if further treatment will be needed.
4. Identify witnesses.
5. Identify the action taken to prevent reoccurrences.

MEDICATION ERROR – Select 8:

1. Identify the correct spelling and name of employee(s) involved including their middle initial;
2. Identify the employee’s title and if a nursing assistant, if he or she is certified;
3. Identify the employee’s date of hire and date of birth;
4. Identify the employee’s social security number;
5. Describe the action, if any, taken with the employee, (if suspended or terminated, identify the dates);
6. Identify if the employee has had previous medication error incidents at your facility;
7. Describe the medication error. Include the time and date of the medication error, the name and dosages of the medication and when it was discovered.

If you believe there is further information relevant to the incident that is not addressed in the questions outlined, please feel free to leave that information at the end of your call.