Azdhs Reportable Event Form PDF Details

In the realm of healthcare and safety, certain occurrences within long-term care facilities mandate prompt reporting to the relevant authorities, one of which is facilitated through the Arizona Department of Health Services (ADHS) Reportable Event form. This detailed document serves as a critical tool for the Division of Licensing Services to capture pertinent information about incidents that occur within these facilities. With a comprehensive layout designed to document every aspect of the event, the form ensures that all incidents — ranging from elopement, injuries of unknown origins, environmental emergencies, neglect, financial exploitation, various types of abuse, to unexpected deaths — are thoroughly reported. The form prompts the reporter to include details such as the date and time of the event, whether it was significant, and who was notified following the occurrence, encompassing law enforcement to family or guardians and even the Arizona Department of Health Services themselves. Moreover, when allegations of abuse, neglect, or misappropriation of funds arise, there is a designated section to gather information regarding the alleged perpetrator, a crucial step towards accountability and preventing future incidents. Completing and submitting this report within five days of the event, as mandated, plays an essential role in ensuring the health, safety, and welfare of residents within these facilities, demonstrating a procedural and robust response to any reportable incidents that may occur.

QuestionAnswer
Form NameAzdhs Reportable Event Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesazdhs reportable event form, event record report, az dhs reportabl e events, az dhs reportable event form

Form Preview Example

Ar izon a Depar t m ent of Healt h Ser vices

Confident ial File

Div ision of Licensing Ser v ices

Dat e: ________

Long Ter m Car e Licensing

I nit : _________

150 N. 18t h Av e. , St e. 440

 

Phoenix , AZ 85007

 

Phone: ( 602) 364 - 2690

 

Aft er Hour s: ( 602) 364 - 2677

 

Fax: (602) 324-0993

 

REPORTABLE EVENT RECORD/REPORT

Please answ er ALL quest ions fully and addr ess only one ev ent per r epor t .

Complete Investigations Include: staff,resident, and witness interviews as well as ALL pertinent information.

* * * Subm it v ia Fax w it hin 5 day s of ev ent * * *

Today 's Dat e ( m m / dd/ yy y y )

Dat e of Ev ent ( m m / dd/ y y y y)

Tim e of Ev ent

AM

PM

Was t his a significant ev ent ?

Yes

No

Was significant ev ent called in?

Yes

No

Full Nam e of Facilit y

St r eet Addr ess

Cit y

St at e

Zip Code

Facilit y Telephone Num ber

Facilit y License Num ber

Provider ID/CCN

Per son Repor t ing

Tit le

Ty p e of I n cid e n t (check all that apply):

 

 

Elopem ent

 

 

 

 

I nj ur y Unk now n Or igin

 

 

 

 

 

 

Env ir onm ent al Em er gency

 

 

 

 

Neglect

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Financial Ex ploit at ion

 

 

 

 

Resident Car e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I nj ur y

 

 

 

 

Resident - t o- Resident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I ncident

 

 

 

 

Abuse St aff - t o- Resident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I nv olunt ar y Dischar ge

 

 

 

 

Abuse Unex pect ed Deat h

 

 

 

 

 

 

 

 

 

 

Ot her , Specify :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

W h o w a s n ot if ie d of t h e occu r r e n ce (check all that apply)?

 

 

 

 

 

 

Law Enfor cem ent - Police Dept . Nam e

 

Case Num ber

 

Officer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nur sing Boar d

Fam ily / Guar dian

 

 

 

Ot her

 

 

 

 

 

 

APS

Medical Examiner

 

 

 

 

 

 

 

 

 

 

Phy sician

Om budsm an

 

 

 

 

 

 

 

 

 

 

Phar m acy Boar d

ADHS (Name of surveyor you spoke to and time you called.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 11/07/2017

Page 1 of 4

REPORTABLE EVENT RECORD/REPORT

(Continued)

I s t he ev ent an allegat ion of abuse, neglect or m isappr opr iat ion of funds? I f y es, com plet e t h e Alleged Perpetrator Information Section.

Yes

No

ALLEGED PERPETRAT OR I N FORM ATI ON

Nam e:

Last

Fir st

MI

Alias

Addr ess:

St r eet / Box

Cit y

St at e

Zip

Telephone Num ber

Dat e of Hir e (mm/dd/yyyy)

AP Suspended?

Yes

No

Dat e (mm/dd/yyyy)

AP Ter m inat ed?

Yes

No

Dat e (mm/dd/yyyy)

CRED EN TI ALI N G/ LI CEN SU RE I N FORM ATI ON

Cer t ificat e or License No.

Ty pe of Cer t ificat ion ( check all t hat apply )

Nur se Aid ( NA)

Cer t ified Nur se Aid ( CNA)

Regist er ed Nu r se ( RN)

Licensed Pr act ical Nur se ( LPN)

Ot her ( specify t y pe: )

 

 

 

Resident Nam e

Dat e of Adm ission (mm/dd/yyyy)

Dat e of Bir t h (mm/dd/yyyy)

Ex a ct Loca t ion of I n cid e n t

N a r r a t iv e :

1)Descr ibe t he ev ent , including t im efr am es/ r isk fact or s r elat ed t o t he incident / ev ent ( r elev ant r esident dx and cognit iv e st at us. If resident to resident altercation is this the first time the resident was involved in an altercation?)

Revised 11/07/2017

Page 2 of 4

REPORTABLE EVENT RECORD/REPORT

(Continued)

2 ) Pr ior t o t he ev ent , w as a plan of car e dev eloped t hat addr essed t his issue, and w er e planned

int er v ent ions in place w hen t he ev ent occur r ed? For ex am ple, a chair alar m or a lap buddy in place.

Yes

No Please descr ibe:

3)

What int er v ent ions w er e im plem ent ed aft er t he incident / ev ent ? For ex am ple, super v ision, r esident sent

t o

hospit al, CNA suspended . Please descr ibe inv est igat iv e findings/ conclusions:

Revised 11/07/2017

Page 3 of 4

REPORTABLE EVENT RECORD/REPORT

(Continued)

Facilit y I nv est igat ion Repor t for Rr esident Abuse, Neglect , Misappr opr iat ion of Pr oper t y , And Ex ploit at ion

of Resident s in Long - Ter m Car e Facilit ies

Use Separ at e sheet for each w it ness/ per son int er v iew ed

W it n e ss St a t e m e n t For m

Dat e:

Tim e:

AM

PM

 

 

 

 

 

Wit ness Full Nam e:

 

 

 

 

 

 

 

 

 

Job Tit le:

 

Shift :

 

 

 

 

 

 

 

Hom e Addr ess:

 

Cit y / Zip

 

 

 

 

 

 

 

Hom e Ph one # :

 

Wor k Ph one # :

 

 

 

 

 

 

 

Relat ion t o Resident : ( I f any )

 

 

 

 

St at e in y our ow n w or ds w hat y ou w it nessed ( be v er y descr ipt iv e) and sign below .

The infor m at ion pr ov ided abov e is t r ue t o t h e best of m y k n ow ledge.

Signat ur e of Wit ness

Dat e

 

 

Revised 11/07/2017

Page 4 of 4

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1. The arizona department of health services reportable event form necessitates specific details to be entered. Make sure the next blanks are filled out:

Filling in part 1 in azdhs reportable event form

2. Now that the previous section is complete, you'll want to put in the needed specifics in Elopem ent Environm ent al Em, I nj ury Unknown Origin Neglect, W h o w a s n ot ifie d of t h e, Law Enforcem ent Police Dept Nam, Case Num ber, Officer, Nursing Board, APS Physician Pharm acy Board, Fam ily Guardian Medical Examiner, Ot her, Revised , and Page of in order to proceed to the next step.

The best way to fill in azdhs reportable event form stage 2

It is easy to make a mistake when filling in the Officer, hence make sure you reread it before you'll finalize the form.

3. Completing I s t he event an allegat ion of, Yes, ALLEGED PERPETRATOR I N FORM ATI, Last, First, Alias, Addr ess, St reet Box, Cit y, St at e, Zip, Telephone Num ber, Dat e of Hire mmddyyyy, AP Suspended, and Yes is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Learn how to complete azdhs reportable event form portion 3

4. Completing Nurse Aid NA Regist er ed Nurse , Cert ified Nurse Aid CNA Licensed, Resident Nam e, Dat e of Adm ission mmddyyyy Dat e, Ex a ct Loca t ion of I n cide n t, and N a r r a t iv e Descr ibe t he is vital in the next step - you'll want to take the time and be attentive with each field!

azdhs reportable event form writing process explained (part 4)

5. This final notch to conclude this form is critical. You must fill out the appropriate fields, and this includes Yes, No Please describe, and What int ervent ions w er e im, before finalizing. Or else, it may end up in a flawed and potentially invalid document!

Filling in segment 5 of azdhs reportable event form

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