Extended Life Home Care’s caregivers have the intentions of providing the best care possible. Unfortunately, instances arise, which makes providing care difficult, change the work relationship, or quite simply make everyone involved uncertain about the future. Extended Life Home Care understands such occurrences, and requires those instances be documented. Proper documentation enables ELHC to be informed, proceed with investigations (if needed), and provide resolution.

Please be as detailed as possible when reporting incidents. As a reminder, incidents should be reported within 24-48 hours of occurring.

 
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Meridiem *
Issue Relation: *
Identify the nature of the incident. *
Identify the nature of the incident. *
Identify the nature of the incident. *

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Did you instruct the caregiver to notify the agency? *
Did the consumer suffer from a fall? *
Consumer's status following fall: *
Did you recommend the consumer to visit the ER for evaluation? *
Did the consumer consult with their physcian or visit the ER? *
Admission Information
 DateTimeHospital NameAdmission Time
Specifics
Was the consumer transported by EMS? *
Did you accompany the consumer? *
Type of abuse suspected or being reported *
PHYSICIAL ABUSE - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *
 WRSUN/A
Unexplained signs of injury such as bruises, welts, or scars, especially if they appear symmetrically on two side of the body
Broken bones, sprains, or dislocations
Report of drug overdose or apparent failure to take medication regularly (a prescription has more remaining than it should)
Broken eyeglasses or frames
Signs of being restrained, such as rope marks on wrists
Caregiver’s refusal to allow you to see the elder alone
EMOTIONAL ABUSE - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *
 WRSUN/A
In addition to the general signs above, indications of emotional elder abuse include:
Threatening, belittling, or controlling caregiver behavior that you witness
Behavior from the elder that mimics dementia, such as rocking, sucking, or mumbling to oneself
Other
SEXUAL ABUSE - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *
 WRSUN/A
Bruises around breasts or genitals
Unexplained venereal disease or genital infections
Unexplained vaginal or anal bleeding
Torn, stained, or bloody underclothing
Other
NEGLECT - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *
 WRSUN/A
Unusual weight loss, malnutrition, dehydration
Untreated physical problems, such as bed sores
Unsanitary living conditions: dirt, bugs, soiled bedding and clothes
Being left dirty or unbathed
Unsuitable clothing or covering for the weather
Unsafe living conditions (no heat or running water; faulty electrical wiring, other fire hazards)
Desertion of the elder at a public place
Other
FINANCIAL EXPLOITATION - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *
 WRSUN/A
Financial exploitation
Significant withdrawals from the elder’s accounts
Sudden changes in the elder’s financial condition
Items or cash missing from the senior’s household
Suspicious changes in wills, power of attorney, titles, and policies
Addition of names to the senior’s signature card
Unpaid bills or lack of medical care, although the elder has enough money to pay for them
Financial activity the senior couldn’t have done, such as an ATM withdrawal when the account holder is bedridden
Unnecessary services, goods, or subscriptions
Other
HEALTHCARE FRAUD AND ABUSE - Identify signs and symptoms in which indicate abuse and/or neglect. Use the following guide (W = Witnessed; R = Reported; S = Suspected, but have not witnessed; U = Uncertain; N/A = Not Applicable, or Not Occuring) *
 WRSUN/A
Claiming and reporting work hours for services not performed.
Evidence of overmedication or undermedication
Failure for coordinating agency/provider to show.
Poorly trained staff, or insufficient staff; inadequate responses to questions about care
Other
Who is suspected of neglecting or abusing the person in question? *
Environmental Changes Affecting Care *
Did you witness the reported incident (were you physically there)? *
I attest to the reported given.  The information contained has been reported as accurate as possible, to the best of my ability.  I understand that I must report this information promptly, and that failure to do so may adversely impact the consumer and potentially my employment.