Information Bulletin 17-04
NH - 180
Hospitals with Swing Beds-7
Immediate Reporting to Administrator
The federal certification regulations under F609 at CFR § 483.12 (c)(1), require that "all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, 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, ... to the administrator of the facility ..."
This informational bulletin provides an option for federally certified nursing facilities to comply with the requirement under F609 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported 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 a report to the administrator under F609 at CFR § 483.12 (c) (1).
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 reporting alleged violations to the administrator, provided that the following are explicitly contained in the policy and procedure as required under F607 at 42 CFR § 483.12(b):
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 Health Regulation Division: firstname.lastname@example.org