PDF State of Nevada Department of Health and Human Services ...
STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
SELF REPORT FORM
According to NAC 449.74491 Any allegation of abuse, neglect, misappropriation of property, elopement, fall/injury, must be reported to the Division of Public and Behavioral
Health within 24 hours. A final report must be received within 5 working days.
PLEASE TYPE IN ALL NECESSARY INFORMATION, THEN FAX TO: 702-486-6520; ATTENTION: SELF REPORT
HAND WRITTEN REPORTS ARE NOT RECOMMENDED
1. FACILITY NAME AND ADDRESS: ___________________________________________________________________________________
2. CONTACT PERSON, PHONE NUMBER AND EMAIL ADDRESS: ___________________________________________________________________________________
3. ALLEGED INCIDENT OCCURRED ON: ___________ AT ___________
AM
PM
(A) RESIDENTS INVOLVED: (ATTACH RESIDENT FACE SHEET)
1. RESIDENT NAME: ______________________________ DATE OF BIRTH: _______________ DATE ADMITTED: ______________________________ ROOM #: _____________________
2. RESIDENT NAME: ______________________________ DATE OF BIRTH: _______________ DATE ADMITTED: ______________________________ ROOM #: _____________________
3. RESIDENT NAME: ______________________________ DATE OF BIRTH: _______________ DATE ADMITTED: ______________________________ ROOM #: _____________________
Page 1 of 6
(B) ALLEGED STAFF INVOLVED (IF APPLICABLE): 1. ALLEGED STAFF: ____________________________________ LICENSE #: _____________ 2. ALLEGED STAFF: ____________________________________ LICENSE #: _____________ 3. ALLEGED STAFF: ____________________________________ LICENSE #: _____________
4. TYPE OF REPORT:
INITIAL
FINAL
INITIAL & FINAL
ADDITIONAL INFORMATION
5. TYPE OF ALLEGED INCIDENT:
RESIDENT TO RESIDENT ALTERCATION EMPLOYEE TO RESIDENT ALTERCATION
ELOPEMENT
RESIDENT FALL
INJURY OF UNKNOWN ORIGIN
MISAPPROPRIATION OF PROPERTY OTHER: ____________________________________
6. BRIEF DESCRIPTION OF EVENT: (ATTACH MEDICAL RECORD REVIEW, CNA RECORDS, INTERVIEWS, X-RAY RESULTS, ETC.)
Page 2 of 6
BRIEF DESCRIPTION CONTINUED:
____________________________________________________________________________________
7. (A) WAS RESIDENT TAKEN TO EMERGENCY ROOM?
YES
NO
(B) WHAT HOSPITAL WAS THE RESIDENT TAKEN TO? ___________________________________________________________________________________
8. DATE RESIDENT RETURNED TO THE FACILITY: _____________________________________ (ATTACH HOSPITAL RESULTS IF APPLICABLE)
9. (A) IF THE PERPETRATOR WAS A STAFF MEMBER, WAS THE ALLEGATION
SUBSTANTIATED?
YES
NO
IF YES, WAS STAFF SUSPENDED?
YES
NO
IF YES, WAS STAFF TERMINATED?
YES
NO
(B) IF ALLEGATION WAS SUBSTANTIATED, PLEASE ATTACH A COPY OF THE LETTER SENT TO THE APPROPRIATE OCCUPATIONAL BOARD. (FOR EXAMPLE: NURSING, PHYSICAL THERAPIST, OCCUPATIONAL THERAPIST, SOCIAL WORKER, RESPIRATORY THERAPIST, ETC)
Page 3 of 6
(C) IF STAFF WAS REINSTATED, DESCRIBE ACTIONS TAKEN: (IF AN INSERVICE WAS HELD, ATTACH ALL SUPPORTING DOCUMENTATION INCLUDING DATE, ATTENDANCE ROSTER, OBJECTIVES, IF IT WAS MANDATORY, ETC.)
___________________________________________________________________________________ CONCLUSION 10. BRIEF DESCRIPTION OF HOW YOU COME TO YOUR CONCLUSION:
(ATTACH FACILITY POLICIES IF APPLICABLE)
___________________________________________________________________________________ Page 4 of 6
11. DESCRIBE OR ATTACH A COPY OF RESIDENT CARE PLAN(S) PERTAINING TO THE INCIDENT:
___________________________________________________________________________________ 12. DESCRIBE ACTION STEPS TAKEN TO PREVENT FUTURE OCCURRENCE:
___________________________________________________________________________________ Page 5 of 6
13. WHAT OTHER ENTITIES WERE NOTIFIED: AGING AND DISABILITY SERVICES LAW ENFORCEMENT: INCIDENT ID # _______________ PUBLIC GUARDIAN FAMILY MEMBER PHYSICIAN OTHER: ________________________________________________________________
PRINT AND FAX TO: 702-486-6520; ATTENTION: SELF REPORT MAKE SURE ALL DOCUMENTS REQUESTED ARE ATTACHED.
PLEASE RETAIN A COPY FOR YOUR RECORDS
Page 6 of 6
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