100-89451_APD 2803

100-89451_APD 2803 (rev 4/23) Page 1 of 7

Nursing Facility Reported

Incident (FRI) Form

Purpose of form: A nursing facility must ensure all alleged violations are reported immediately to

the administrator of the facility and to other officials, including the State Survey Agency (SSA), in

accordance with §483.12(c)(1). A nursing facility should use this form to report FRIs that meet

§483.12(c)(1) to

Oregon’s SSA, Safety, Oversight and Quality (SOQ), Nursing Facility (NF)

Complaint Intake Unit.

Reporting time frames:

Immediately but no later than 2 HOURS after the allegation is made - If the alleged violation

involves abuse (refer to Federal abuse definitions) or results in serious bodily injury (refer to

Federal definition) or reasonable suspicion of a crime if the events that cause the suspicion result in

serious bodily injury.

No later than 24 HOURS after the allegation is made - If the alleged violation/crime does not

involve abuse and does not result in serious bodily injury.

Please complete all sections of this form.

What Alleged Violation are You Reporting: (Choose all that apply)

Mistreatment

Exploitation

Neglect

Abuse

Injuries of Unknown Source

Misappropriation of Resident Property

Suspected Crime

Has the alleged violation resulted in serious bodily injury: Yes No

Facility Information:

Today’s date: Time: a.m. p.m.

Facility’s complete (full) name:

Facility’s CCN Number:

Address:

City: State: ZIP code:

Phone number:

Name of person reporting this incident to the NF Complaint Intake Unit for the facility:

Last: First:

Title: Email:

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Incident Details:

Incident date:

Time:

a.m. p.m.

Incident location (be as specific as possible):

Date and time staff first aware of incident: Date: Time:

a.m.

p.m.

Incident Reporting:

First:

Name of person who reported incident to facility administration: Last:

Staff title or

relationship

to resident: Date reported:

Date and time Administrator notified of incident: Date: Time:

a.m. p.m.

Description of Incident – All parts of this section must be completed.

Describe the incident:

Describe outcome to the

involved resident/s:

identify any physical, psychosocial, or

behavioral, adverse effect or injury to the resident/s:

Describe what immediate protective

asures were put in place

to prevent this

incident from

curring to the resident

or other

resident(s):

Incident time unknown:

Inciden t date unknown:

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Yes No

Date of birth:

Firs t: Gender:

Medicaid number (if applicable):

Resident 1

Name: Last:

Medicaid: Yes

Relevant diagnosis:

Has Resident 1 been involved in a similar allegation or incident before:

Yes No

Is Resident 1 still in the facility: Yes

No If no, where is Resident 1 now:

First: Gender: Date of birth:

Resident 2

Name: Last:

Medicaid: Yes

No Medicaid number (if applicable):

Relevant diagnosis:

Has Resident 2 been involved in a similar allegation or incident

before: Is Resident 2 still in the facility: Yes No

If no, where

is Resident 2 now:

Are there additional Residents: Yes No If yes, list name(s):

List All Residents Involved in the Incident:

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Reported Perpetrators (RP) (Do not list a resident as a reported perpetrator on this form.)

Reported Perpetrator 1 (RP1) Name:

Last:

First:

Phone:

Staff title or relationship to resident:

License or certificate number:

If RP1 is a staff person, are they on administrative leave:

Yes No

If RP1 is not a staff person, do they have access to the resident or other residents at the

facility:

Yes No

Phone:

First:

Reported

Perpetrator

2 (RP2) Name:

Last:

Staff title or relationship to resident:

License or certificate number:

If RP2 is a staff person, are

they on administrative leave:

Yes

Is RP2 is not a staff person, do they have access to the resident or other residents at the

facility:

Yes

If more than two RPs are involved, please list them here:

Witnesses:

Yes No If yes, list witnesses:

Phone:

First:

Did anyone witness the incident:

Witness Name: Last:

Staff title or

relationship

to resident:

Witness Name: Last:

Staff title or

relationship

to resident:

Are there additional Witnesses:

Yes

No If yes, list name(s):

Please

Answer of

All the Following Questions:

Is this incident a crime:

Yes No

If yes, has law enforcement been notified:

Yes No If yes, date and time notified.

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ontact:

this incident:

Phone:

Law enforcement agency and agency contact:

Case number, if known:

List

anyone else contacted:

The information provided and attached with this form assists with FRI triage prioritization.

Please include other relevant documentation with this FRI, (e.g., care plan, applicable MARs,

applicable progress notes, etc.) via secure email. Save a copy of the completed FRI form

before sending. Ensure the form displays all information when faxing.

First:

Name of person completing this form: Last:

Title: Date:

Please note: The facility must report the results of all alleged violation investigations to the

SSA within 5 working days of the incident. (CFR §483.12(c)(4))

After clicking the “SUBMIT” button below, a new email message will appear, and the “To”

section of the email message should automatically be filled in as, “Facility Reported

Incidents” and the FRI form will be attached. Please:

1. Add the Facility’s complete name to the Subject line of the email.

2. Send email via secure email.

Note: Your completed FRI Form will automatically attach to the email when you click the

“SUBMIT” button below.

SUBMIT

If you are unable to use the “Submit” button as designed, please email the completed

form to the Nursing Facility Complaint Unit via secure email to:

FRI.incidents@odhsoha.oregon.gov

If you are unable to email the form, please fax the completed form to the Nursing

Facility Complaint Unit at Fax: 1-888-550-6788.

For questions regarding this form, please call: 1-877-280-4555.

SUBMIT

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Glossary

(As defined at CFR §483.12(a-c))

Abuse: “The willful infliction of injury, unreasonable confinement, intimidation, or punishment

with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by

an individual, including a caretaker, of goods or services that are necessary to attain or

maintain physical,

mental, and psychosocial well-being. Instances of abuse of all residents,

irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.

It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse

facilitated or enabled through the use of technology.”

Alleged Violation: “Is a situation or occurrence that is observed or reported by staff, resident,

relative, visitor or others but has not yet been investigated and, if verified, could be

noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or

abuse, including injuries of unknown source, and misappropriation of resident property.”

CCN: Centers for Medicare & Medicaid Services (CMS) Certification Number (CCN), formerly

the Medicare Provider Number, is used to verify Medicare/Medicaid certification for survey

and certification, assessment-related activities and communications.

Crime: “A crime” is defined by law of the applicable political subdivision where the facility is

located. A political subdivision would be a city, county, township or village, or any local unit of

government created by or pursuant to State law.” “Examples of situations that would likely be

considered a crime in all subdivisions would include, but are not limited to:

• Murder;

• Manslaughter;

• Rape;

• Assault and battery;

• Sexual abuse;

• Theft/Ro

bbery;

• Drug diversion for personal use or gain;

• Identity theft; and

• Fraud and forgery.”

Exploitation: “Taking advantage of a resident for personal gain, through the use of

manipulation, intimidation, threats or coercion.”

Immediately: “As soon as possible, in the absence of a shorter State time frame requirement,

but not later than 2 hours after the allegation is made, if the events that cause the allegation

involve abuse or result in serious bodily injury, or not later than 24 hours if the events that

cause the allegation do not involve abuse and do not result in serious bodily injury.”

Injuries of unknown source: “An injury should be classified as an “injury of unknown source”

when

both of the following criteria are met:

• The source of the injury was not observed by any person or the source of the injury

could not be explained by the resident;

and

• The injury is suspicious because of the extent of the injury or the location of the injury

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(e.g., the injury is located in an area not generally vulnerable to trauma) or the number

of injuries observed at one particular point in time or the incidence of injuries over time.”

Misappropriation of resident property: “The deliberate misplacement, exploitation, or wrongful,

temporary, or permanent use of a resident’s belongings or money without the resident’s

consent.”

Mistreatment: “Inappropriate treatment or exploitation of a resident.”

Neglect: “The failure of the facility, its employees or service providers to provide goods and

services to a resident that are necessary to avoid physical harm, pain, mental anguish or

emotional distress.”

Serious bodily injury: “An injury involving extreme physical pain; involving substantial risk of

death; involving protracted loss or impairment of the function of a bodily member, organ, or

mental faculty; requiring medical intervention such as surgery,

hospitalization,

or physical

rehabilitation;

or an injury resulting from criminal sexual abuse (See section 2011(19)(A) of the

Act).”

Sexual Abuse: “Non-consensual sexual contact of any type with a resident.”

Criminal sexual abuse: In the ca

se of “criminal sexual abuse” which is defined in section

2011(19)(B) of the Act, serious bodily injury/harm shall be considered to have occurred if the

conduct causing the injury is conduct described in section 2241 (relating to aggravated sexual

abuse) or section 2242 (relating to sexual abuse) of Title 18, United States Code, or any

similar offense under State law. In other words, serious bodily injury includes sexual

intercourse with a resident by force or incapacitation or through threats of harm to the resident

or others or any sexual act involving a child. Serious bodily injury also includes sexual

intercourse with a resident who is incapable of declining to participate in the sexual act or

lacks the ability to understand the nature of the sexual act.

Willful: As used in the definition of “abuse,” “means the individual must have acted

deliberately, not that the individual must have intended to inflict injury or harm.”