Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long Term Care Facilities




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ARKANSAS DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF MEDICAL SERVICES

OFFICE OF LONG TERM CARE

Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property,

& Exploitation of Residents in Long Term Care Facilities




Purpose/Process

This form is designed to standardize and facilitate the process for the reporting allegations of resident abuse, neglect, or misappropriation of property or exploitation of residents by individuals providing services to residents in Arkansas long term care facilities. This investigative format complies with the current regulations requiring an internal investigation of such incidents and submittal of the written findings to the Office of Long Term Care (OLTC) within five (5) working days.


The purpose of this process is for the facility to compile a substantial body of credible information to enable the Office of Long Term Care to determine if additional information is required by the facility, or if an allegation against an individual(s) can be validated based on the contents of the report.


Completion/Routing



This form, with the exception of hand written witness statements, MUST BE TYPED!
Complete all spaces! If the information cannot be obtained, please provide an explanation, such as “moved/address unknown”, “unlisted phone”, etc. Required information includes the actions taken to prevent continued abuse or neglect during the investigation.
If a requested attachment can not be provided please provide an explanation why it can not be furnished or when it will be forwarded to OLTC.
This form, and all witness and accused party statements, must be originals. Other material submitted as copies must be legible and of such quality to allow re-copying.
The facility’s investigation and this form must be completed and submitted to OLTC within five (5) working days from when the incident became known to the facility.
Upon completion, send the form by certified mail to:

Office of Long Term Care, P.O. Box 8059, Slot 404, Little Rock, AR 72203-8059.


Any other routing or disclosure of the contents of this report, except as provided for in LTC 306.3 and 306.4, may violate state and federal law.

Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property,

And Exploitation of Residents in Long-Term Care Facilities.




Section 1 - Reporting Information




Name of Facility:

     




Phone:

(   )

     




Address:

     




City:

     

State:

AR

Zip Code:

     




Facility Staff Member Completing DMS-762:

     




Title:

     




Date Incident Reported to OLTC:

     

Time:

     






Date and Time of Incident (if known):

     

Time:

     






Date and Time of Discovery:

     

Time

     






Type of Incident:

Neglect:






Misappropriation of Property:

Drugs


















Personal Property






Abuse:

Verbal






Resident’s Trust Fund









Sexual












Physical












Emotional/Mental









Name of Involved Resident:

     

Room #

     




Social Security #:

     

DOB:

     




Height:

     

Weight:

      lbs.

Physician

     




Is Resident Still Living?

 Yes

 No

If not, Date of Death

     




Ambulatory?

 Yes

 No

Oriented

 Time

 Place

 Person

 Event




Physical Functional Level/Impairment

     




Mental Functional Level

     




Primary Diagnosis

     

Section II - Complete Description of Incident
See Attached” Is Not Acceptable!


     

Section III - Findings and Actions Taken
Please include Resident’s current medical condition


     






















Facility Administrator’s or Designee’s Signature




Date

Section IV - Notification/Status
Administrator/Written Designee Must Be Notified!


Name of Administrator

     




Date

     

Time

     






Family Notified

 Yes

 No

 None

Date

     

Time

     






Name of Family Member

     







Relationship

     

Phone #

(   )

     




Doctor Notified

 Yes

 No

Date

     

Time

     






Doctor’s Name

     

Phone #

(   )

     




Resident Sent To Hospital

 Yes

 No

Date

     

Time

     






Name/Address/Phone of Hospital

     










     










     

Phone

(   )

     




Law Enforcement Must Be Notified For Abuse And Neglect




Date

     

Time

     






Name of Law Enforcement Agency

     




Phone #

(   )

     




Address

     




City/Zip

     




Was an Investigation Made by the Law Enforcement Agency?

 Yes

 No




Date of Investigation

     

Time

     






Name of Officer

     




Section VI - Accused Party Information




Name of Accused Party

     




Job Title (if any)

     

Phone #

(   )

     




Home Address

     




City/State/Zip

     




Social Security #

     

DOB

     




Dates of Current Employment

From

     

To

     




Certified Nursing Assistant

 Yes

 No




Registration #

     

Date Issued

     




Date Criminal Background Check Completed

     




Licensed by State Board of Nursing

 Yes

 No




Type of License

RN #

     

LPN #

     




Date Issued

     






Section VII- Attachments

Attach the following information to the back of this form. If you do not have one of the specified attachments, please provide an explanation why it cannot be obtained or if it will be forwarded in the future.




  1. Statement from the accused party.




  1. All witness statements. Use the attached OLTC Witness Statement Form for all witness statements submitted. If the statement is a typed copy of a handwritten statement, the handwritten statement must accompany the typed statement.




  1. Law enforcement incident report. This can be mailed at a later date if necessary.




  1. Other pertinent reports/information, such as Ombudsmen, autopsy, reports, etc. These can be mailed at a later date if necessary.

Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property,

And Exploitation of Residents in Long-Term Care Facilities










OLTC Witness Statement Form




Date

     

Time

     






Witness Full Name

     




Job Title

     

Shift

     




Home Address

     

City/Zip

     




Home Phone #

(   )

     

Work Phone #

(   )

     




Relation to Resident (If Any)

     




State in your own words what you witnessed (be very descriptive) and sign below.




     




The information provided above is true to the best of my knowledge.










Signature of Witness

     

Date

     

Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property,

And Exploitation of Residents in Long-Term Care Facilities










OLTC Witness Statement Form




Date

     

Time

     






Witness Full Name

     




Job Title

     

Shift

     




Home Address

     

City/Zip

     




Home Phone #

(   )

     

Work Phone #

(   )

     




Relation to Resident (If Any)

     




State in your own words what you witnessed (be very descriptive) and sign below.




     




The information provided above is true to the best of my knowledge.










Signature of Witness

     

Date

     

Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property,

And Exploitation of Residents in Long-Term Care Facilities










OLTC Witness Statement Form




Date

     

Time

     






Witness Full Name

     




Job Title

     

Shift

     




Home Address

     

City/Zip

     




Home Phone #

(   )

     

Work Phone #

(   )

     




Relation to Resident (If Any)

     




State in your own words what you witnessed (be very descriptive) and sign below.




     




The information provided above is true to the best of my knowledge.










Signature of Witness

     

Date

     




DMS-762

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