Misconduct Incident Report (Page 2 of 8) in pdf

F-62447 (Rev. 04/10)

Page 2 of 8

VII. DESCRIBE OR ATTACH A COPY OF THE ENTITY’S INVESTIGATIVE RECORDS CONCERNING THE INCIDENT (Page 6)

Provide all relevant information found during the entity’s internal investigation, including the following:

STAFF INFORMATION

CLIENT INFORMATION

Accused individual’s personnel records, including but not limited

Pertinent medical records, including but not limited to the person’s

to training records, disciplinary records, time cards or sheets for

plan of care or treatment plan at the time of the incident.

the period during which or date(s) the incident occurred.

Ambulance run report, if applicable.

Witness time cards or sheets for the period or date(s) the

Any relevant hospital admission and discharge documents.

incident occurred.

Photographs of visible injuries or affected property.

Staff schedule, roster, or assignment sheets for the time period

Financial account statements, including account numbers and

or date(s) the incident occurred.

balance information.

Statements from the accused individual and witnesses relating to

Statements about the incident.

the incident.

Sign-off sheets indicating completion of cares pertinent to the

LAW ENFORCEMENT INFORMATION

incident.

Law enforcement officer’s narrative reports.

Photographs.

ENTITY INFORMATION

Entity’s policies and procedures related to the incident.

OTHER INFORMATION

Photographs and diagram or illustration of the scene where the

Any other records that may apply.

incident occurred with relevant information included, i.e.,

locations of witnesses, client, and pertinent objects at the time of

the incident.

VIII. PERSON PREPARING THIS REPORT (Page 6)

Provide the name, position or title, and telephone number of the person preparing this report. The person preparing this report must sign and

date this form in the space provided.

IX. WRITTEN STATEMENT (Page 7)

Ask the affected client, the accused person, and all other persons with information about the incident to provide written statements.

If the entity uses its own forms to obtain written statements about the incident, the entity may attach those forms to the Incident Report. If

the entity attaches its own written statements to the report form, the facility should ensure that each person completing a written statement

provides the identifying information requested on the report form and signs the statement.

The entity is advised to follow up on written statements by asking probing questions to gather as much detail as possible, including what

happened, how the incident happened, when it happened, where it happened, reactions at the time of the incident, and other witnesses

who may have been present. It is suggested that the entity use the FOLLOW UP QUESTIONS (Page 8) following the written statement

form as a guide when questioning the accused person.

MANDATORY REPORTING TIMELINES

▪

FEDERALLY CERTIFIED NURSING HOMES AND FEDERALLY CERTIFIED INTERMEDIATE CARE FACILITIES FOR PERSONS WITH

DEVELOPMENTAL DISABILITIES

Upon the completion of the entity’s internal investigation of the incident, send the completed form, any available documentation, and the results

of your investigation within 5 WORKING days (Monday – Friday, excluding legal holidays) of the date the entity knew or should have known of

the incident.

▪

ALL OTHER ENTITIES

Upon the completion of the entity’s internal investigation of the incident, send the completed form, any available documentation, and the results

of your investigation within 7 CALENDAR days of the date the entity knew or should have known of the incident.

MAILING INSTRUCTIONS

NOTE: All complaints regarding both credentialed staff (e.g., RN, LPN, MD) and non credentialed staff (e.g., nurse aides, personal care

workers, housekeepers) will be tracked by the Department of Health Services, Division of Quality Assurance (DQA). DQA will refer

complaints that involve credentialed staff to the Department of Regulation and Licensing for investigation.

Send the completed form and any supporting documentation to:

Department of Health Services

Division of Quality Assurance

Office of Caregiver Quality

P.O. Box 2969

Madison, WI 53701-2969

You may also send forms via:

E-mail:

DHSCaregiverIntake@dhs.wisconsin.gov

Fax: (608) 264-6340

DIRECT QUESTIONS REGARDING THIS FORM TO (608) 261-8319.

Misconduct Incident Report Page 2

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