Form 6111, Limited Services Rural Hospitals Incident Report

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Effective Date

10/2024
6111.pdf

Instructions

Effective Date: 10/2024

Purpose

Form 6111 is used to notify Texas Health and Human Services Commission (HHSC) of an incident and the actions taken by the facility.

Procedure

Submit each form separately within the required time frame of the incident:

  • As soon as possible:
    • Abuse, neglect or exploitation
    • Illegal, unprofessional or unethical conduct
    • Abuse or neglect of a child
    • Abuse or neglect of a person with a mental illness
    • Abuse, neglect or exploitation of an elderly or disabled person
    • Abuse or neglect of a person with mental illness
  • As soon as possible, but not later than 10 calendar days following the occurrence:
    • All occurrences of fire to HHSC

Do not submit multiple incidents in one document.

Explain how the facility will improve care as a result of the incident. Complete the entire form with all requested attachments so HHSC may review the incident without requiring additional information or documents.

Transmittal

Submit each completed form by one of the following:

Email: CII.HCQ@hhs.texas.gov
Fax: 833-709-5735 or 512-206-3985
Mail: Texas Health and Human Services Commission
Complaint and Incident Intake
P.O. Box 149030, Mail Code E-249
Austin, TX 78714-9030

Detailed Instructions

Print or type the information and provide as much information as possible. Use the facility name and license number as listed on your license.

Reportable Incident – Check the appropriate box from the following:

  • Abuse, neglect or exploitation
  • Illegal, unprofessional or unethical conduct
  • Abuse or neglect of a child
  • Abuse, neglect or exploitation of an elderly or disabled person
  • Abuse or neglect of a person with mental illness
  • All occurrences of fire

Date of Report – Enter the report date.

Date of Death – Enter the date of death.

Time of Death – Enter the time of death.

Facility License No. – Enter the facility license number.

Facility Provider No. (CCN) – Enter the facility provider number, which is the Medicare six-digit number.

Facility Name – Enter the name of the facility.

Facility Address – Enter the street address, city, state, ZIP Code.

Area Code and Phone No. – Enter the area code and phone number.

Reporter Name and Title – Enter the contact person and title the surveyor will ask for should a follow-up phone call be needed.

Primary Area Code and Phone No. and Secondary Area Code and Phone No. – Enter the area code and phone numbers.

Email – Enter the email address.

Patient First, Middle and Last Name – Enter the patient’s name.

Date of Birth – Enter the patient’s date of birth.

Date of Admission and Time of Admission – Enter the date the patient was admitted and the time.

Date of Discharge and Time of Discharge – Enter the date the patient was discharged and the time.

Date of Death and Time of Death – Enter the date and time the patient died.

Patient resides in Hall, Unit, Floor, Room – Provide the hall number or name, room number or floor number where the patient is staying.

Suspected Cause of Death – Enter the suspected cause of death.

All Diagnoses – Enter the diagnoses including level of supervision and prior history of similar incidents.

Name of Procedure – Enter the name of the procedure.

Discharge Disposition – Check the box for home, hospital, nursing home or other. If other, enter the other disposition.

Transfer Facility Name and City – Enter the name of the facility and city.

Baby First, Middle, Last Name – Enter the name.

Date of Birth or Event – Enter the date of birth or event.

Baby Gender – Check the box for male or female.

Time of Death – Enter the hour and minute of death.

Date of Discharge – Enter the date of discharge.

All Diagnoses – Enter the diagnoses.

Second Baby First, Middle, Last Name – If a second baby, enter the name.

Second Date of Birth or Event – If a second baby, enter the date of birth or event.

Second Baby Gender – If a second baby, check the box for male or female.

Time of Death – If a second baby, enter the hour and minute of death.

Date of Discharge – If a second baby, enter the date of discharge.

All Diagnoses – If a second baby, enter the diagnoses.

Note: If incident involves more than two fetuses or infants, attach additional documentation.

Medical Provider Name – Enter the name of the medical provider who provided medical services to the patient.

Title – Enter the title of the medical provider.

License No. – Enter the license number of the medical provider.

Physician Performing Procedure – Enter the first and last name of the physician.

License No. – Enter the physician's license number.

Witness First, Middle, Last Name – Enter the name of the witness. Witnesses can include other patients, staff members, family members and friends.

Title – Enter the title of the witness if the witness is a staff member.

Area Code and Phone No. – Enter the phone number of the witness.

Alleged Perpetrator First, Middle, Last Name and Title – Enter the alleged perpetrator’s name and title. List only alleged perpetrators who are not patients. Alleged perpetrators who are patients should be listed in the Patient section. If the alleged perpetrator is not a patient or a staff member, indicate the relationship of this person to the patient, such as a friend or family member.

Alleged Perpetrator License No. – Enter the alleged perpetrator’s license number.

Social Security No. – Enter the alleged perpetrator’s Social Security number.

Area Code and Phone – Enter the alleged perpetrator’s area code and phone number.

Alleged Perpetrator Address – Enter the alleged perpetrator’s street address, city, state and ZIP Code.

Summary

When did you first learn of the incident? – Enter the date and time.

On what shift did the incident occur? – Check the box for day, evening or night.

Provide a summary – Enter what happened and include relevant staff names and titles, dates and time. Include information that clarifies if the patient was transferred before death.

Did the patient sustain injuries? – Check Yes or No. If yes, explain the injuries.

Did the patient receive treatment at the Limited Services Rural Hospital? – Check Yes or No. If yes, explain the treatment provided. Attach pertinent treatment documentation, if necessary.

Were any diagnostic tests performed such as X-ray, CT scan, MRI, ultrasound, PET scan, blood work or other? – Check Yes or No. If yes, provide diagnostic test results.

Does the patient have a history of elopements, suicidal ideations or attempts, self-harming behaviors or other? Check Yes or No. If yes, explain.

Was a psychiatric assessment performed? Check Yes or No. If yes, provide psychiatric assessment results.

Is the patient under an emergency detention order? Check Yes or No.

Did the patient transfer to another facility? Check Yes or No. If yes, provide the name and address of the facility.

Provide a narrative report of the investigation – Explain how  the incident was handled and what actions were taken to reduce the potential for similar incidents in the future.

Referrals – Check all boxes that apply and the report number for each.

Actions to be taken as a result of this incident – Check all boxes that apply.

Signature, Printed Name and Date – The supervising authority signs, prints their name and enters the date. Email, fax or mail the completed incident form to the number or address provided above under Transmittal.