ALLEGATIONS OF ABUSE Internal Occurrence Reporting and Investigation

Objectives After completion of the module, the employee will be able to: Define abuse and neglect Discuss the policy of CHSB’s role regarding reporting of abuse Enumerate procedures for reporting and notification of abuse Discuss other important roles that other disciplines and/or departments will be responsible for

Introduction

Purpose To provide guidelines and a chain of command for CHSB staff to immediately report any allegation made by a patient or visitor of physical, sexual or other misconduct To assure timely notification of appropriate licensing and regulatory agencies to protect patient safety and employee rights

Definition Abuse Willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish Includes staff neglect or indifference to infliction of injury or intimidation of one patient by another neglect – failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness

Policy CHSB will: Identify events and occurrences that may constitute or contribute to abuse and neglect Complete an objective investigation of all allegations of abuse, neglect or mistreatment in a timely and thorough manner Carry out appropriate corrective, remedial or disciplinary action in accordance with applicable hospital policy, local, state or federal law Complete required notification to law enforcement, mandated reporting agencies and regulatory bodies in a timely manner

Procedures

Procedures Complainant Protection and Support A CHSB staff member who witnesses or is told of any incident that could be construed as abuse, neglect or harrassment will immediately notify his/her Department Manager and the House Supervisor Assurance will be given to the complainant that a thorough investigation will be done and law enforcement, mandated reporting agencies, and regulatory bodies will be notified as appropriate Complainant will be informed of the outcome of the investigation to the extent permitted by law

Procedures Complainant Protection and Support If the complainant is a patient, consideration will be given to changing room, unit assignment, providing for a sitter or arranging for a family member/friend to stay with the patient, making the patient “no info” and/or changing the nurse/other care giver assigned to the patient

Reporting & Notification Staff Member the staff member hearing or witnessing the allegation will report the incident to the charge nurse, supervisor or manager immediately or within one hour of hearing or witnessing the incident social services will be triggered if complainant is a patient HR designee will be informed of the incident if or when the employee is involved in the allegation Charge Nurse the Charge Nurse or Supervisor will notify the patient’s physician of the allegation as soon as possible the Charge Nurse, Supervisor or Manager will notify the Department Director and the House Supervisor who then will notify Public Safety, Risk Management and the Administration-on-call, and will provide name, location and nature of allegation

Reporting & Notification House Supervisor the House Supervisor, in conjunction with the Director of Risk Management, will notify the patient’s family of the allegation as soon as possible Director of Risk Management the Director of Risk Management will notify the Chief Medical Officer or his designee if or when the allegation includes a Licensed Individual Practitioner Clinical Social Worker the Clinical Social Worker will notify Adult Protective Services (APS) or Child Protective Services (CPS) as appropriate

Reporting & Notification Director of Public Safety The Director of Public Safety or designee will obtain and complete a report and will notify local law enforcement as appropriate after receiving notification of the allegation

Documentation When the Complainant is a Patient the staff member that initially received the allegation will document a brief factual note in the medical record including the following information, but excluding the names of the alleged subjects(s): inappropriate conduct by staff, date and time of allegation brief allegation statement (e.g. “patient reported possible inappropriate conduct by staff; chain of command activated”)

Documentation the primary nurse or charge nurse will document the date and time the physician was notified the Director of Risk Management will document the date and time the family was notified The staff member receiving the allegation will utilize the CHSB Event Reporting System (ERS) to assist with identification of opportunities to improve care.

Other Important Roles

Roles – Risk Management Notify Administration as soon as possible of any allegation that may necessitate notification to a mandated reporting agency and/or regulatory body, and/or if there is a potential for media involvement In conjunction with Administration, complete notification to the appropriate mandated reporting agency(s) and/or regulatory bodies Collaborate with Public Safety and Human Resources to complete a thorough investigation of the alleged events Inform the complainant of the outcome of the investigation to the extent permitted by law

Roles - Public Safety Obtain and complete report of the allegation and contact law enforcement as appropriate Meet law enforcement personnel and escort them to the complainant’s location to facilitate police investigation Provide a written report to the Director of Risk Management within 24 hours of receiving the allegation. This will include the name of the officer who interviewed the complainant and the report number Request a written report from law enforcement and provide the report to the Director of Risk Management when received

Roles – Human Resources Participate in the investigation with the Public Safety and Risk Management Departments when the allegation involves an employee An employee identified in the allegation will immediately be placed on administrative leave and continue an administrative leave until the investigation is completed Manage employee involvement and resolution Collaborate with Risk Management to report findings of the completed investigation to Administration

Roles – Social Services Meet with the complainant (if patient) within 24 hours of the complaint and provide consultative services and make recommendations for treatment or follow up as indicated Coordinate completion of notification to mandated reporting agencies as appropriate Report will be phoned in to the 24-hour hotline and followed by a written report within 36 hours to Child Protective Services (CPS) or law enforcement if applicable Report will be phoned in to Adult Protective Services (APS) immediately and followed by a written report within 48 working hours, if applicable Fax completed abuse reporting form to the Vice-President or Chief Nursing Officer or other applicable Vice-President, as appropriate

Roles - Administration In conjunction with the Director of Risk Management, will determine the extent of reporting to licensing and regulatory agencies Involve the Public Relations Department in cases where there may be media involvement

Training All employees will be provided with information regarding abuse and neglect, and related reporting requirement including prevention, intervention and detection This training will be provided during orientation and through an ongoing training program