AUTHORITY The following rules and regulations for the - Arkansas ...

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Facility Investigation Report <strong>for</strong> Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long Term Care Facilities Section I-Reporting In<strong>for</strong>mation Name of Facility: Phone #: ( ) Address: City State Zip Code Facility Staff Member Completing DMS 762: Title: Date Incident Reported/Faxed to OLTC: Time: AM/PM Date & Time of Incident (if known):_______________________________________________________________________ Time & Time of Discovery:______________________________________________________________________________ Type of Incident: Neglect Misappropriation of Property: Drugs Abuse: Verbal Personal Property Sexual Resident's Trust Fund Physical Emotional/Mental Name of Involved Resident: Room # : Social Security #: DOB: Height____________Weight____________Physician______________________________________________ Is Resident still Living: If not, Date of Death: Ambulatory? YES NO Oriented Time, Place, Person, Events (Circle one or all). Physical Functional Level/Impairment Mental Functional Level Primary Diagnosis Residential Care Facilities R. 08/01/07
Section II-Complete Description of Incident “See Attached Is Not Acceptable!” (Attach Additional Pages as Necessary) 35 Residential Care Facilities R. 08/01/07
Page 1 and 2: AUTHORITY The following rules and r
Page 3 and 4: 600 MEDICATIONS ………………
Page 5 and 6: 4. The imminence of the potential h
Page 7 and 8: In order to determine if an alterat
Page 9 and 10: 204 APPLICATION, EXPIRATION AND REN
Page 11 and 12: The Department is empowered to deny
Page 13 and 14: adequate level of service and assis
Page 15 and 16: 3. Assures the full protection of r
Page 17 and 18: f. Must not have been convicted of
Page 19 and 20: f. Policies and procedures must be
Page 21 and 22: g. The employee's signed acknowledg
Page 23 and 24: the provision of a written notifica
Page 25 and 26: easons other than appropriateness o
Page 27 and 28: All written incident and accident r
Page 29 and 30: ARKANSAS DEPARTMENT OF HUMAN SERVIC
Page 31 and 32: SUMMARY OF INCIDENT - CONTINUED DMS
Page 33: ARKANSAS DEPARTMENT OF HUMAN SERVIC
Page 37 and 38: Section IV- Notification/ Status Ad
Page 39 and 40: Facility Investigation Report for R
Page 41 and 42: a b c d e f g h Any waiver of the r
Page 43 and 44: 3. Resident mentally incapacitated:
Page 45 and 46: 312.9 Each resident is assured conf
Page 47 and 48: a. During any medical examination o
Page 49 and 50: n. An entry shall be made at any ti
Page 51 and 52: h. Residents are not routinely conf
Page 53 and 54: 501.7 Food service employees must i
Page 55 and 56: c. First-aid supplies shall be avai
Page 57 and 58: 702.2 The facility shall have full
Page 59 and 60: 11 Bed linens must be changed at le
Page 61 and 62: 2. A single bedroom must contain at
Page 63 and 64: a. Portable electric space heaters
Page 65 and 66: 713.3 All gas heating units must be
Page 67 and 68: 12. Testimony shall be taken only o
Page 69 and 70: . The severity and scope of the act
Page 71 and 72: Class B violations and the points a
Page 73 and 74: All Class D violations shall be ass
Page 75: APPENDIX C ARKANSAS STATUTES AS REF

AUTHORITY The following rules and regulations for the - Arkansas ...

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