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 Mandatory Reporting Requirements for Nursing Homes  
 Completion of this form is required to meet the requirements in Federal regulation 42 CRF 483.13(c)(2). Nursing homes must immediately report incidents of alleged mistreatment, abuse and neglect of residents (including injuries of unknown source), and misappropriation of resident property to the Division of Quality Assurance (DQA), the state survey and certification agency. The Centers for Medicaid and Medicare Services (CMS) defines "immediately" to be as soon as possible but not to exceed 24 hours after discovery of the incident. Failure to provide the following information to DQA within 24 hours of discovering an incident may result in the issuance of a statement of deficiency.   

 
  Because the federal definitions do not specify that an incident has to involve a caregiver, nursing homes are required to submit allegations of mistreatment by anyone, including residents.

Note that the federal definition of abuse indicates that the act needs to be "willful" and that it needs to have resulted in physical or psychosocial harm to the resident or would be expected to have caused harm to a "reasonable person" if the resident cannot provide a response.

For a definition of "willful," please refer to the interpretive guidelines at F323 where, under Resident-to-Resident Altercations, it notes, "An incident involving a resident who willfully inflicts injury upon other resident should be reviewed as abuse under the guidance for 42 CFR 483.13(b) at F223. 'Willful' means that the individual intended the action itself that he/she knew or should have known could cause physical harm, pain or mental anguish. Even though a resident may have a cognitive impairment, he/she could still commit a willful act."




   
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Enter ABUSE, NEGLECT, MISAPPROPRIATION or INJURY
 
   
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Enter UNKNOWN if accused is not known or INJURY if injury of unknown source.
 
   
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Enter UNKNOWN if accused is not known or INJURY if injury of unknown source.
 
   
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  Questions about this completed form may be directed to the DQA Office of Caregiver Quality at DHSCaregiverIntake@dhs.wisconsin.gov or 608-261-8319. To print a copy of this report, click on your browser's print button before you click on the Done button below.

Upon completion of the facility's investigation and within 5 days of the date discovered, the nursing home must submit an Incident Report F-62447 with supporting documentation to the DQA Office of Caregiver Quality.
   
 
 
 
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