Information Bulletin 13-01
HOSPITALS WITH SWING BEDS-1
Immediate Reporting To Administrator
The federal certification regulations under F225 at CFR § 483.13 (c)(2), require 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…"
This informational bulletin provides an option for federally certified nursing facilities to comply with the requirement under F225 that all alleged violations of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator.
This process must be used only when the administrator is not present in the facility.
Facilities are not required to adopt the process outlined in this bulletin.
The facility may designate individual(s) having the delegated authority of the administrator for compliance with the requirement of an immediate report to the administrator under F225 at CFR § 483.13 (c) (2).
POLICY AND PROCEDURE
If the facility adopts this process, it must establish a policy and procedure and operationalize.
In the absence of the administrator from the facility, the facility's policy must designate individual(s) who have the administrative authority of the administrator for purposes of immediate reporting alleged violations to the administrator, provided that the following are explicitly contained in the policy and procedure as required under F226 at 42 CFR § 483.13(c):
The designated individual has been delegated authority by the administrator to:
- Intervene in any situation in order to protect residents.
- Remove any individual from the facility if necessary for the protection of residents or staff, including but not limited to employees, visitors, contractors, or family members.
- Call local law enforcement for assistance with interventions necessary for the protection of residents or staff.
- Call 911 for any type of emergency assistance.
The facility staff must know this facility policy and procedure and must know who to report to with administrative authority.
For more information, please contact our Division of Compliance Monitoring Program: firstname.lastname@example.org