Alternative Required Healthcare Facility Event Reporting
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Report Type
Report Type
This form is intended to be used as an initial report by a healthcare facility staff member who has no facility login to the online event reporting page. This form is not intended for use by the public.
Initial
Facility
Facility
Select Your Type:
Please select
ALC
Ambulatory Surgery Center
End Stage Renal Dialysis
FQHC
Home Health
Hospice
Hospital
LTC
Other
Rural Health
Name of Facility:
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Name of Facility:
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Name of Facility:
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Name of Facility:
Please select
Name of Facility:
Please select
Name of Facility:
Please select
Name of Facility:
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Name of Facility:
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Name of Facility:
Please select
Name of Facility:
Please select
Email Address(es):
Patient/Resident Information
Patient/Resident Information
First Name:
Last Name:
Date of Birth:
Age:
Cognition Score:
Admission Date:
Pertinent Diagnoses:
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Event Reporting
Event Reporting
Name of Person Completing Report:
Credentials of Person Completing Report:
Facility Contact Person:
Date of Event:
Time of Event:
Type of Event Being Reported:
Please select
Death, other than natural causes
Disaster/fire/loss of utilities
Missing patient/resident
Suspicion/allegation of abuse/neglect
Allegation Type:
Please select
Physical harm/injury
Misappropriation of property/funds
Use of profanity, gestures, acts
Neglect
Fall
Elopement
Other
Please specify:
Suspicion/Allegation of Abuse/Neglect:
Please select
Elopement
Facility personnel
Fall
Family or visitor
Other
Resident to resident/Patient to patient
Please specify:
Victim's First Name:
Victim's Last Name:
Cognition Score:
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Is the individual capable of providing an explanation of the event or capable of participating in investigation?
Yes
No
Provide a brief explanation of event being reported. Please include name(s)
of Patient/Resident/Personnel/Family/Visitors involved with event:
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Describe the immediate interventions put into place to protect the resident
while the investigation is ongoing.
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Allegation involved facility personnel?
Yes
No
For each PERSONNEL involved, please provide the following information:
Full Name:
Job Title:
License/Certification #:
Date of Birth:
Date of Hire:
Last Known Address, City, State, Zip;
Phone #:
If terminated, date of termination:
Previous Disciplinary Actions:
Please select
No
Yes
Is this person a CNA?
Please select
No
Yes
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Notifications
Notifications
Law Enforcement Notification
Law Enforcement Notification
Notify law enforcement
only for
an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person.
Law Enforcement Notified?
Yes
No
Why or why not?
Who:
When:
Case Information:
Board of Nursing (BON) Notification and Filing of Licensee or Registrant Complaint
Only
complete the BON’s
Complaint Form
, pursuant to
SDCL 36-1C
, if you want the BON to investigate a nurse or registrant (CNA or Med Aide) for a suspected violation of the grounds for discipline in
SDCL 36-9-49
or
ARSD 20:48:16:04
; and
only
if you have evidence to support the alleged complaint and violation.
Complaint Form Submitted to BON?
Yes
No
Why or why not?
Department of Human Services (DHS) Notification
Department of Human Services (DHS) Notification
Notify DHS at
DHS.DOHReports@state.sd.us
for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person.
DHS (
not
the Ombudsman)? APS worker notified?
Yes
No
Why or why not?
Who was notified and when?
Family/Person of Authority (POA) Notification
Family/Person of Authority (POA) Notification
Family or POA notified?
Yes
No
Why or why not?
Physician Notification
Physician Notification
Physician notified?
Yes
No
Why or why not?
Health Department Notification
Health Department Notification
Date Notified:
Time Notified:
Investigation Conclusion
Investigation Conclusion
Conclusionary summary statement of facility investigation (Please include
all specific interventions put in place to prevent further occurrences):
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Upload File
Upload File
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or
Maximum files: 10.
Uploaded File(s)
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for recommendations on uploading files.
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