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REPORTING REQUIREMENTS

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					                        REPORTING REQUIREMENTS
                  ILLINOIS DEPARTMENT OF PUBLIC HEALTH

State of Illinois: Section 300.690 Serious Incidents and Accidents


       a)      The facility shall maintain a file of all written reports of each incident and
               accident affecting a resident that is not the expected outcome of a
               resident's condition or disease process. A descriptive summary of each
               incident or accident affecting a resident shall also be recorded in the
               progress notes or nurse's notes of that resident.

       b)      The facility shall notify the Department of any serious incident or
               accident. For purposes of this Section, "serious" means any incident or
               accident that causes physical harm or injury to a resident.

       c)      The facility shall, by fax or phone, notify the Regional Office within 24
               hours after each reportable incident or accident. If the facility is unable to
               contact the Regional Office, it shall notify the Department's toll-free
               complaint registry hotline. The facility shall send a narrative summary of
               each reportable accident or incident to the Department within seven days
               after the occurrence.



Federal: 42 CFR 483.13(c) (2) and (4).

(2)    “The facility must ensure that all alleged violations involving
mistreatment, neglect, or abuse, including injuries of unknown source, and
misappropriation of resident property are reported immediately to the
administrator of the facility and to other officials in accordance with State law
through established procedures (including to the State survey and certification
agency).”

(4)     “The results of all investigations must be reported to the administrator or
his designated representative and to other officials in accordance with State law
(including the State survey and certification agency) within 5 working days of the
incident, and if the alleged violation is verified appropriate action must be taken.”




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Events reportable to the Illinois Department of Public Health include, but
are not limited to:

   1) Any serious incident or accident. "Serious" means any incident or accident
      that causes physical harm or injury to a resident. The incidents and
      accidents that should be reported include, but are not limited to:
          a. Elopement:
                   i. An elopement of a resident from the facility that results in a
                      serious injury, as defined by the new IDPH regulations.
                  ii. A resident who has poor community survival skills (“red
                      dot”) and is missing from the facility for more than 24 hrs.
                 iii. Any resident who is missing from the facility for any
                      period of time where facility has reasonable cause to
                      believe or has knowledge that the resident may be harmed
                      or is otherwise injured.
          b. AWOL:
                   i. Resident who facility has determined to be safe in the
                      community is missing from the facility and facility has
                      reasonable cause to believe or has knowledge that the
                      resident may be harmed or is otherwise injured.

       *** Facility should still notify the local police department immediately
       per facility’s elopement policy.

          c. Death of a resident that is unusual or a result of an accident;
          d. Serious injury to a resident. These injuries include, but are not
             limited to:
                  i. Injury that is sustained while the resident is physically
                     restrained;
                 ii. Large areas of contusion, bruises, hematomas of an
                     unknown origin: (a) 8 cm or larger, or (b) requiring hospital
                     services, or (c) located on resident’s breast or genital areas;
                     and
                iii. Lacerations requiring hospital treatment that involves more
                     than a diagnostic evaluation.
          e. Significant medication, treatment or nursing error leading to
             serious injury;
          f. Attempted suicide with injury or actual suicide by a resident;
          g. Serious injury/death related to equipment;
          h. Burns greater than 1st degree;
          i. All fractures;
          j. Bites resulting in serious injury (requiring hospital treatment that is
             more than a diagnostic evaluation);
          k. Eye injuries resulting in serious injury (requiring hospital treatment
             that is more than a diagnostic evaluation);




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      l. Serious injuries to residents when out on pass (requiring hospital
          treatment that is more than a diagnostic evaluation). These injuries
          may include, but are not limited to: falls, automobile accidents and
          etc.;
      m. Poisoning resulting in serious injuries (requiring hospital treatment
          that is more than a diagnostic evaluation); and
      n. Scabies.
2) Any allegation of resident abuse and neglect (verbal or physical)
      a. Physical. Includes, but is not limited to:
                i. Resident to resident altercation;
               ii. Staff to resident altercation;
             iii. Visitor to resident altercation;
              iv. Hitting a resident;
               v. Slapping a resident;
              vi. Pinching a resident; and
             vii. Controlling behavior through corporal punishment.
      b. Mental. Includes, but is not limited to:
                i. Humiliation;
               ii. Harassment; and
             iii. Threats or punishment or deprivation.
      c. Verbal. Includes, but is not limited to:
                i. Use of oral, written or gestured language that willfully
                   includes disparaging and derogatory terms to residents or
                   within their hearing distance, regardless of their age, ability
                   to comprehend or disability;
               ii. Threats of harm; and
             iii. Saying things to frighten a resident (ex: telling a resident
                   that he/she will never be able to see his or her family).
      d. Sexual
                i. Sexual harassment;
               ii. Sexual coercion; and
             iii. Sexual assault.
              iv.
3) Other reportable events:
      a. An interruption which interferes with the health and safety of the
          residents in one or more of major utilities to the facility, such as
          electrical, water supplies, plumbing, sewage disposal, heat or air
          conditioning, fire alarms, sprinkler systems or phone service.
      b. Significant events that have a serious effect on operations of the
          facility (ex: tornado, flood and etc.).




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Definitions:

"Abuse" means any physical or mental injury or sexual assault inflicted on a
resident other than by accidental means in a facility. It is the willful infliction of
injury, unreasonable confinement, intimidation or punishment with resulting
physical harm, pain, or mental anguish. This also includes the deprivation by an
individual, including a caretaker, or goods or services that are necessary to attain
and/or maintain physical, mental or psychological well-being. This assumes that
all instances of abuse of residents, even those in a coma, cause physical harm of
pain or mental anguish.

"Neglect" means a failure in a facility to provide adequate medical or personal
care or maintenance, which failure results in physical or mental injury to a
resident or in the deterioration of a resident's physical or mental condition.

"Misappropriation of a resident's property" means the deliberate misplacement,
exploitation, or wrongful temporary or permanent use of a resident's belongings or money
without the resident's consent.




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