HOSPITAL FAX REPORTING
OF INCIDENTS AND ABUSE

GENERAL INSTRUCTIONS:

1.	These instructions apply to reporting all hospital incidents, and suspected abuse, neglect, mistreatment and misappropriation of patient property under the Patient Abuse Law.                                                

2.	Complete a separate blank form for each occurrence following the instructions below.

3.	Use the attached tables to enter a description for those items that are marked “see table.”

4.	Submit your completed report by fax to the Department immediately for (1) fires; (2) suicide; (3) serious criminal acts; (4) pending or actual strike; (5) serious physical injury or harm to a patient resulting from accident or unknown cause; and, (6) suspected abuse, neglect, mistreatment or misappropriation involving nursing home, rest home, home health, homemaker and hospice patients.  Notify the Department immediately by phone at 617-753-8150 of any deaths resulting from incidents, medication errors, abuse or neglect; and full or partial evacuation of the facility for any reason.  Submit other completed reports within seven days of the date of the occurrence of an incident seriously affecting the health and safety of patients.

5.	Fax your completed report to the Department at 617-753-8165.

LINE BY LINE INSTRUCTIONS

FROM:  Please provide the name and address of the facility making the report.  

DATE OF REPORT:  Enter the date that you are submitting your report to the Department.

FOR ABUSE, NEGLECT, MISTREATMENT or MISAPPROPRIATION OCCURING IN NURSING HOME, REST HOME, HOME HEALTH, HOMEMAKER OR HOSPICE SETTING, NOT AT THE REPORTING HOSPITAL:

FACILITY/AGENCY NAME: Indicate the name of the provider at which the suspected abuse, neglect, mistreatment or misappropriation occurred.

ADDRESS:  Indicate the address (city or town, if street address is not known) of the
provider at which the suspected abuse, neglect or misappropriation occurred.

Please indicate the date and time of the occurrence.  If you are not able to determine when the event occurred, state “unknown”.

PATIENT INFORMATION:  Please provide information here regarding the patient involved.  The information reported here should reflect the patient’s condition prior to the occurrence.  If more than one patient was injured, or if one patient has injured another patient, provide additional patient information under the narrative portion of the report or on an additional page.  Please indicate:
NAME:  The patient’s first and last name.  

AGE; SEX; ADMISSION DATE:  Enter each for the named patient.

AMBULATORY STATUS:  Select the term from Table #1, “Ambulatory Status”, that most closely describes the patient’s ability to walk.

ADL STATUS:  Activities of Daily Living (ADLs) such as eating, dressing or personal grooming. Select the term from Table #2, “Patient ADL Status”, that most closely describes the patient’s ability to perform these functions.

COGNITIVE LEVEL:  Select the term from Table #3, “Patient Cognitive Status”, that  best describes the patient’s cognitive status at the time of the occurrence.

MENTALLY RETARDED/DEVELOPMENTALLY DISABLED:  Indicate whether or not the patient is mentally retarded or developmentally disabled.  If the resident is either, indicate the name of the Service Coordinator (mentally retarded) or Case Manager (developmentally disabled) assigned to the patient, if known.
RACE/ETHNICITY: Indicate the Patient’s Race and Ethnicity. Complete the Hispanic Indicator.  The rules for coding race and ethnicity and the Hispanic Indicator are the same as used by the Division of Health Care Finance and Policy in its inpatient discharge data submission regulations.  See the instructions in the Electronic Records Submission Specification: http://www.mass.gov/Eeohhs2/docs/dhcfp/g/regs/114_1_17_hdd_data_specs.doc 
	The details are on page 25 of this document.

DPH OCCURRENCE TYPE:  For all reports, select the term from Table #4, “Occurrence Type”, that best describes the occurrence you are reporting.  You may select “Other” and describe what happened in one or two words if none of the examples listed are applicable to your report.

SERIOUS REPORTABLE EVENT:  Indicate whether or not this is a report of a “serious reportable event” as described in the current National Quality Forum (NQF) list of serious reportable events (SRE).  If it is an SRE, check of the type of SRE on the table on page 2.  For additional information regarding NQF see http://www.qualityforum.org/pdf/news/prSeriousReportableEvents10-15-06.pdf  

TYPE OF HARM:  Select the term from Table #5, “Type of Harm”, that best describes the harm or injury that resulted from the occurrence. You may select “Other” and describe what happened in one or two words if none of the examples listed are applicable to your report. Note that harm includes psychological injury as well as physical harm, and SHOULD NOT BE DESCRIBED AS “NONE” SIMPLY BECAUSE THERE WAS NO PHYSICAL HARM.

BODY PART AFFECTED:  Use terms such as “arm”, “foot”, etc.; indicate left or right when it applies.

PATIENT’S ACTIVITY AT TIME OF OCCURRENCE:  Select the term from Table #6, “Patient’s Activity” that best describes the patient’s activity at the time of the occurrence.  You may select “Other” and describe what happened in one or two words if none of the examples listed are applicable to your report.

PLACE OF OCCURRENCE:  Specify where the event occurred.  Examples would include: “patient’s room”, “dining room”, “shower room”, or any other short phrase that specifies the type of setting in which the occurrence took place.

WHAT EQUIPMENT, IF ANY, WAS BEING USED AT TIME OF OCCURRENCE:  Specify if any equipment was in use, such as “Hoyer lift”, or “walker”.

ANY SAFETY PRECAUTIONS IN PLACE:  Check the “yes” or “no”.  If “yes”, describe the precautions that were in place. 

NARRATIVE:  Describe fully what occurred.  Indicate who, what, when, where, why and how what is being reported occurred.  Include information on how any person injured was treated.  If there were any unusual circumstances involved, describe these fully.

CORRECTIVE MEASURES NARRATIVE:  Describe what actions have been taken in response to the occurrence.  

GENERAL INFORMATION:  Please indicate your name and title, as the person preparing this report, a phone number at which we can contact you if we need additional information, and the date and time of the occurrence.  If you are not able to determine when the event occurred, state “unknown”.

STAFF PERSON IN CHARGE OF FACILITY AT TIME OF OCCURRENCE:  Indicate who was present and in charge at the facility (not on the unit) when the occurrence reported happened.  

NOTIFICATION:  Indicate whether or not the patient’s family and physician, and police were notified.  Provide the name of the physician notified.  

	WITNESS INFORMATION:  List the name and title for individuals who saw or heard what occurred.  Indicate if any of witnesses were directly involved in what occurred.  Other patients, visitors and volunteers should be listed as witnesses if they have direct knowledge of what occurred.

ACCUSED INFORMATION: When reporting suspected abuse, neglect or misappropriation, indicate the name of the accused, a phone number at which the accused can be contacted, if the accused is a nurse, nurse aide or other licensed professional please indicate the individual’s license or registration number.  Check the appropriate block if you are not reporting abuse, or the identity of the person(s) suspected of abuse, neglect or misappropriation of a patient’s money or belongings is unknown.  If more than one individual is suspected, indicate on an additional sheet the other individual’s names, a phone number at which they may be contacted, and if any person was acting as a nurse aide, home health aide or homemaker.

	REPORTING TABLES:

Table #1:  Ambulatory Status:				Table #2:  Patient ADL Status:

Independent							Independent
Supervised							Supervised
Dependent/Assist						Dependent
Wheels Self							Unknown
Wheelchair							Other
Bedfast
Unknown

Table #3:  Patient’s Cognitive Status:			Table #4:  Occurrence Type:

Alert/Oriented							Fall 
Dementia							Abuse
Confused							Neglect 
Alzheimer’s							Misappropriation
Comatose							Surgical Error
Unknown							Medication Error
Other								Accident
								Emergency Services
Table #5: Type of Harm:					Death
								Suicide
Fracture							Infection Control
Laceration							Criminal Act
Bruise/Hematoma						Fire
Reddened Area						Pending Strike
Dislocation							Equipment Malfunction
Burn								Injury of Unknown Origin
Unwelcome Sexual Contact/Advance			            Other (Describe)
Emotional Harm/Upset
Care Not Provided						Table #6:  Patient’s Activity 
Quality of Care
Decline in Condition						Ambulating
Infection							Toileting
Confinement							Transfer/Assist
Property							Getting Out of Bed
Funds								Getting Up From Chair
Death								Reaching
No Harm							Standing/Sitting Still
Other (Describe)						Crowded Area
Unknown							Other(Describe)
								Unknown

HOSPITAL FAX REPORT FORM

TO:	 INTAKE STAFF 
	 DEPARTMENT OF PUBLIC HEALTH, DIVISION OF HEALTH CARE QUALITY
	 FAX NUMBER: 617-753-8165

FROM:  Hospital Name:	__________________________________________
	  Address (Street):	__________________________________________
	  Address (City/Town)	__________________________________________

DATE OF REPORT:	  	_______________	NUMBER OF PAGES:  ____________

IF ABUSE, NEGLECT, or MISAPPROPRIATION IN A NURSING HOME, REST HOME, HOME HEALTH, HOMEMAKER, OR HOSPICE AGENCY AND NOT THE REPORTING HOSPITAL:
ABOUT: Facility/Agency Name:__________________________________________
	  Address:                   	___________________________________________

DATE OF OCCURRENCE:	Month____________ Date_________ Year________
TIME OF OCCURRENCE:	________________________ am______ pm_______

PATIENT INFORMATION:
Name:				First ________________ Last__________________
Age:				______________
Sex:				Male _________   Female __________
Admission Date:		Month___________ Date__________ Year________
Ambulatory Status (See table #1):________________________________________
ADL Status (See table #2):	___________________________________________
Cognitive Level (See table #3):___________________________________________
Mentally Retarded/Developmentally Disabled: ____ Yes ____No.  
 If yes, Service Coordinator or Case Manager (if known): _________________________

RACE:								HISPANIC INDICATOR
___Asian ___Black/African American ___ White			__ Patient is Hispanic/Latino/Spanish
___ American Indian/Alaska Native 				__ Patient is not Hispanic/Latino/Spanish
___ Native Hawaiian or Other Pacific Islander 
___ Unknown/Not Specified
___ Other Race (specify) _____________________

ETHNICITY: Please check all that apply:
___Cuban	___ Asian Indian	___ Honduran	
___Dominican	___ Brazilian	___ Japanese	
___ Mexican/Mexican American/Chicano
___ Puerto Rican	___ Cambodian
___ Cape Verdean 	___ Korean 
___ Laotian 	
___ Salvadoran	___ Caribbean Island	___ Middle Eastern	
___ Central American (not specific)	___ Chinese	___ Portuguese	
___ South American (not specific)	___Columbian	___ Russian	
___ African	___ European	___Eastern European	
___ African American	___ Filipino	___ Vietnamese	
___ American	___ Guatemalan	___ Other Ethnicity	
___ Asian	___ Haitian	___ Unknown/Not Specified	
[Page 1 of 4.]
REPORTING HOSPITAL: __________________  DATE OF OCCURRENCE: _________

DPH Occurrence Type (See table #4):___________________________________
Is this a serious reportable incident as defined by NQF ____ Yes ____No.   
If yes, indicate type(s) below:
___ Artificial insemination with the wrong donor sperm or donor egg 			
___ Unintended retention of a foreign object in a patient after surgery or other procedure
___ Patient death or serious disability associated with patient elopement (disappearance)
___ Patient death or serious disability associated with a medication error (e.g., errors  involving the wrong 	drug, wrong 	dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration) 	
___ Patient death or serious disability associated with a hemolytic reaction due to the  administration of ABO/HLA-	incompatible blood or blood products
___ Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a 	healthcare facility 
___ Patient death or serious disability associated with a fall while being cared for in a	healthcare facility 
___ Surgery performed on the wrong body part 	
___ Surgery performed on the wrong patient 	
___ Wrong surgical procedure performed on a patient 	
___ Intraoperative or immediately post-operative death in an ASA Class I patient 	
___ Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided 	by the 	healthcare facility 
___ Patient death or serious disability associated with the use or function of a device in patient care, in which the device is 	used or functions other than as intended 	
___ Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in 	a 
       healthcare facility       	
___ Infant discharged to the wrong person 	
___ Patient suicide or attempted suicide resulting in serious disability, while being cared for in a healthcare facility 	
___ Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a 	health care facility 	
___ Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being 	cared for in a healthcare facility 	
___ Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates 	
___ Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility 	
___ Patient death or serious disability due to spinal manipulative therapy 	
___ Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is 	contaminated by toxic substances 	
___ Patient death or serious disability associated with a burn incurred from any source while being cared for in a 	healthcare facility 	
___ Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a 	healthcare facility 	
___ Any instance of care ordered by or provided by someone impersonating a physician, nurse, 	pharmacist, or other 	licensed healthcare provider 	
___ Abduction of a patient of any age 	
___ Sexual assault on a patient within or on the grounds of the healthcare facility 	
___ Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs 	within or   on the grounds of the healthcare facility 

[Page 2 of 4.]
REPORTING HOSPITAL: __________________  DATE OF OCCURRENCE: _________

Type of Harm (See table #5):__________________________________________
Body Part Affected:		__________________________ L:_____  R: _____
Patient’s activity at time of
 occurrence (See table #6):	__________________________________________
Place of Occurrence:		__________________________________________
What equipment, if any, was being
 used at time of occurrence?	__________________________________________
Any safety precautions in place? Yes________  No_________
 If yes, describe what precautions were in place:  

NARRATIVE: (Please address the following: What happened?  What factors contributed to the occurrence?  Any relevant information which establishes cause?  Have there been similar incidents in the past?  How were the injuries treated?  [Attach additional pages as needed.] )

	
Were there any unusual circumstances involved? Yes________ No__________ If yes, please describe.  [Attach additional pages as needed.]

[Page 3 of 4.]
REPORTING HOSPITAL: __________________  DATE OF OCCURRENCE: _________

CORRECTIVE MEASURES NARRATIVE – Please address the following:   
  N/A - Incident occurred with another provider _______. 
  Was there an internal investigation: Yes_____ No_____     If No - why?  If yes - what are the investigation findings?   
  What action was taken with regard to: Patient?; Staff?; Facility practice?    What is the patient's current status?  
  What corrective action taken regarding equipment involved, if applicable?    [Attach additional pages as needed.] )

GENERAL INFORMATION:
Report prepared by:		___________________________________________
Title:				___________________________________________
Phone Number:		(________)__________-___________Ext:_________

STAFF PERSON IN CHARGE OF FACILITY AT TIME OF OCCURRENCE:
N/A (Incident occurred with another provider):_______
Name:					Title:			Directly Involved:
_____________________________________________________YES_____NO_______

NOTIFICATION:
Was family notified:		Yes__________  No_____________
Was MD notified:		Yes__________  No_____________
Name of MD if notified:  	_________________________________________ 
Were  police notified: 		Yes__________  No_____________

WITNESS INFORMATION:	        (Check here if unwitnessed: ____________)
Name:					Title:		          Directly Involved:
_____________________________________________________YES_____NO_______
_____________________________________________________YES_____NO_______

ACCUSED INFORMATION:  (Check here if unknown or not applicable: _________)
Name:					Telephone #:			
________________________________(_____)_____-_______  
AIDE ___; RN/LPN ____
If RN/LPN or other licensed individual, indicate license #:______________________

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