Required Healthcare Facility Event Reporting

FOR HEALTH CARE FACILITY USE ONLY
For all other complaints or concerns please call (605)773-3497 or email doholccomplaint@state.sd.us
Instructions:

  • If you are submitting your initial and final report together and are within the initial reporting timeframe, please select final.
  • To include multiple facility e-mail addresses, separate them with a semi-colon (;)
  • To attach files or view attached files, please save/submit your report.
  • * = Required field
Report Type:



Facility:

Full Facility Name
Facility Email Address
City
Facility Phone Number
Facility Fax Number
Facility Type
Patient/Resident Information:

First Name
Last Name
Date of Birth
Age
Cognition Score
Event Reporting:

Name of Person Completing Report
Credentials of Person Completing Report
Facility Contact Person
Date and Time of Event
Type of Event Being Reported
Ambulance notified?


Date and time Ambulance was notified
EMTs involved?


Date and time EMTs were involved
Police notified?


Date and time Police were notified
Why not?
Allegation Type
OTHER, Please Specify:
Suspicion/Allegation of Abuse/Neglect
OTHER, Please Specify:
Victim
Cognition Score
Is the individual capable of providing an explanation of the event or capable of participating in investigation?


Provide a brief explanation of event being reported. Please include name(s) of Patient/Resident/Personnel/Family/Visitors involved with event:

Allegation involved
facility personnel?
For each PERSONNEL involved, please provide the following information:
Full Name
Job Title
Social Security Number
License/Certification Number
Date of Birth
Date of Hire
Last Known Address, City, State, Zip
Phone Number
If terminated, date of termination
Previous Disciplinary Actions

Law Enforcement Notification:
Notify law enforcement Only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person.

Law Enforcement Notified?


Why or why not?
Date and time Law Enforcement notified
Law Enforcement Entity Notified:
Name and number of Officer contacted:
Department of Human Services (DHS) Notification:
Notify Dakota At Home (1-833-663-9673) Only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person.

DHS (NOT the Ombudsman)? APS worker notified?


Why or why not?
Date and time DHS was notified
Name and number of Worker contacted
Health Department Notification:

Date and time Health Department notified
Investigation Conclusion:

Conclusionary summary statement of facility investigation: (Please include all specific interventions put in place to prevent further occurrences)

Substantiation and Action:

Was abuse/neglect allegation substantiated?



Why or why not?
If a patient/resident was suspected of abuse/neglect, was it a willful act?



Action taken by the facility
(Check all that apply)


OTHER, Please Specify
Accepted means the report has been received and we have no further questions about that report.