Training: Caregiver Misconduct, Neglect and Misappropriation
Scroll down to take the required Quiz
Policy and Procedure
Purpose: This policy sets forth the procedure for investigating and reporting caregiver misconduct and
injuries of an unknown source.
Policy: Caregiver misconduct includes the abuse and neglect of a resident or the misappropriation of the
resident’s property by an employee of the facility.
All staff will be trained regarding the procedures to be followed when misconduct, abuse or misappropriation is
suspected. The initial training will be done during orientation. The training form will be then signed by the
All residents/responsible parties of the facility will receive a Residential Admission Agreement which includes
the reporting procedures to follow when suspected misconduct and misappropriation occurs. All residents
and/or their families will sign a signature sheet indicating they received and understand the information.
Residents will be instructed to report the suspected misconduct to the Director of Resident Services or
Administrator. If neither is available, the resident is to report the information to the charge nurse on duty. In
the event that the charge nurse is not available, the resident will report the information to a staff member who
will follow the chain of command in reporting the incident.
An employee is required to report a suspected misconduct or injury of unknown source, or any circumstances
which would lead them to reasonably suspect or believe that misconduct or injury has occurred, to the charge
nurse on duty. An injury of unknown source is one which occurs to a resident but was not observed by any
person or the source of the injury cannot be explained by the resident; and the injury is suspicious because of
the extent of the injury or the location of the injury. The charge nurse will report the information to the Director
of Resident Services who will, in turn, report the information to the Administrator. If there is no charge nurse on
duty, the employee is to notify the Administrator. All reporting is to be completed promptly of learning of the
incident (regardless of the time of day or day of the week.) At that time, all necessary steps will be taken to
protect our residents from possible subsequent incidents of misconduct or injury.
Employees may learn of an incident from a resident who asserts either verbally or in writing what transpired; by
a resident who may either verbally or in writing indicate what he/she observed happen to another resident; by a
verbal or written statement by an individual who is in a position to know about the incident; discovering the
incident after it occurred; hearing about the incident form others; observing the injuries to a resident; observing
misappropriation of a resident’s property or otherwise becoming aware of an incident.
Upon notification of the suspected case of misconduct or misappropriation, the Administrator and Director of
Resident Services will conduct a thorough investigation to determine what, if anything, happened and determine
the factual circumstances surrounding the alleged incident. All aspects of the investigation will be documented
clearly and concisely.
Physical and documentary evidence will be collected and preserved as a part of the investigation. This includes,
but is not limited to, photographs of injuries, diagrams and interviews with alleged victims and witnesses.
Evidence will be organized in a manner which will either corroborate or disprove initial evidence.
Other regulatory authorities such as the Sheriff’s Department, Elder Abuse Agency and Adult Protective
Services may be asked to assist in the investigation.
Each step taken in the investigation will be carefully documented. The investigation will concentrate on
questions such as:
1. When did the incident occur? At what time? What staff members were on duty?
2. Who was present at the time of the incident? Was anyone else present in the vicinity of the incident
who would have knowledge of the incident?
3. Did anyone hear, see or overhear the incident and what exactly was seen and heard?
4. What exactly happened? How did it happen?
5. Where did the incident occur? Be specific – room number, type of furnishings, etc. Were there any
physical obstructions in the line of sight of the witness?
6. Are there any reasons to believe that the incident could not have possibly occurred?
The facility will report to the Bureau of Quality Assurance all incidents of suspected misconduct or
misappropriation. The report to the BQA is made when:
1. The facility has reasonable cause to believe we have sufficient information and evidence or another
regulatory authority could obtain the evidence, to show the alleged incident occurred; and
2. The facility has reasonable cause to believe the incident meets, or could meet, the definition of abuse,
neglect or misappropriation.
Completed incident reports of alleged caregiver misconduct will be submitted to BQA within seven calendar days
of the incident or the date the facility knew of the incident.
The facility must conduct an internal investigation but is not required to submit the Incident Report Form to the
BQA relative to the incident if either of the following is true: the facility does not believe it has or another
regulatory authority could obtain sufficient evidence to show the abuse, neglect or misappropriation, and the
facility is reasonably certain that the incident does not meet the definition of caregiver misconduct or the
definition if an injury of unknown source.
The facility must maintain a file for inspection by the BQA of the 30 most recent internal investigations that
were not forwarded to the BQA. The facility may still use the Incident Report to document the incident and the
internal investigation results.
The facility will report incidents to the BQA using the Misconduct Incident Report Form: F-62447. The form is
to be completed and submitted to BQA at:
Department of Health Services
Division of Quality Assurance
Office of Caregiver Quality
PO Box 2969
Madison WI 53701-2969
When the alleged misconduct involves staff members who are licensed by the Department of Regulations and
Licensing (registered nurses, licensed practical nurses, physicians, social workers, etc.) the same mailing
address may be used.
While the alleged incident may violate facility policy, the facility may appropriately discipline or terminate the
employee for a particular incident, even though the BQA may determine that misconduct is unable to be
Any employee decision against the employee while a complaint is pending is a facility decision. The facility is
not required to suspend or terminate an employee against whom an allegation is made or reported. The facility
may, during the period, increase supervision of the employee, provide an alternate work assignment, give verbal
or written reprimands, suspend or terminate the employee.
The facility will not employ or contract with a person who has direct, regular contact with a resident, if the
employee has a finding of misconduct on the Wisconsin Caregivers Registry unless the employee has received a
Rehabilitation Review approval.