DETECTION AND PREVENTION OF ABUSE AND NEGLECT Quality Improvement Nurse Consultants

BACKGROUND INFORMATION CMS (HCFA) RESPONSE TO ABUSE & NEGLECT: Standardized definition Identification of residents at risk Specified contributing factors Developed a national strategic approach

RULES AND REGULATIONS The Feds say: Report, report!! Investigate and--- Report again!!

Where do you find the Federal Requirements? CFR (c) (1) (iii) CFR (c) (2) CFR (c) (3) CFR (c) (4)

TAG ALONG F 223 Abuse F 224 Freedom from Mistreatment, Neglect or Misappropriation of Resident Property F 225 Prevention and Reporting F226 Policies and Procedures

STATE OF MICHIGAN LAWS M Tag 0090 Section (1) Facility staff of a nursing home shall not physically, mentally, or emotionally abuse, mistreat, or harmfully neglect a patient. (2) When aware of a violation of Number 1, go directly to Number 2; i.e., report the matter to the administrator (employees); report the matter to the Michigan Department of Community Health (administrators). (3) Any person may report a violation to the Department. (4) A physician or other licensed health care personnel of a hospital or other health care facility to which a patient is transferred who becomes aware of an act prohibited by this section shall report the act to the Department.

STATE OF MICHIGAN LAWS (5) The Department investigates after receiving report and may request additional info. (6) A licensee or nursing home administrator shall not evict, harass, dismiss, or retaliate against a patient, a patient’s representative, or an employee who makes a report under this section

STATE OF MICHIGAN LAWS Section also requires the reporting of other occurrences which threaten the welfare, safety, or health of residents, such as: a. Resident to-resident altercations that result in injuries that interfere with vital physiologic functions which are an immediate threat to life or have a strong potential to become an immediate threat to life. Multiple (3 or more) resident-to-resident altercations by a specific resident. b. Elopement of a resident/patient missing for more than 2 hours and/or has a strong potential to become an immediate threat to life and/or neglect. c. Injuries of unknown origin that result in interference with physiologic functions which are an immediate threat to life or have a strong potential to become an immediate threat to life and or abuse.

TERMS TO REMEMBER ABUSE- the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. NEGLECT- The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness

TYPES OF ABUSE/NEGLECT Physical abuse Sexual assault Misuse of restraints Emotional or psychological abuse Verbal abuse Involuntary seclusion Medical neglect Abandonment Financial or material exploitation

WHAT TO LOOK FOR? Bruises, black eyes, welts, lacerations, rope marks, imprint injuries Fractures Open wounds, cuts, punctures Sprains or dislocations Unexplained VD or genital infections Unexplained vaginal/anal bleeding Bruises around breast/genital area

WHAT TO LOOK FOR? (CONT.) Malnutrition Contractures Pressure Ulcers Certain psychosocial behaviors

State of Michigan Interim policy for reporting Alleged Abuse, etc.. Proposal Alleged violations of abuse, mistreatment, neglect, etc. are reported to the administrator The investigation commences immediately, while the residents are safeguarded

Incidents-Involving Harm Are to be reported immediately to the Bureau of Health Systems (BHS) BHS-OPS Hour Report Completed Recorded on BHS Facility Log Investigation commences, while residents are safeguarded

Incidents-Involving Harm (cont.) Report results of your investigation to BHS, complete the BHS-OPS-363, 5 day report form Record the investigation results on the BHS Facility Log Harm means some physical injury or damage, pain, or mental anguish

Incident-Without Harm Recorded on BHS Facility Log Investigation commences, while residents are safeguarded Investigation results reported to administrator Facility takes corrective action as needed

BHS Facility Log -- Expectations  Facilities begin recording on 12/1/06.  Facilities send BHS Facility Log to Licensing Officer on/or about 1/15/07.  Licensing Officer or designee reviews BHS Facility Log upon receipt for timeliness of entries, completeness, understanding of harm.  Licensing Officer works with facilities, as appropriate, to ensure the BHS Facility Log is correct.

BHS Facility Log -- Expectations BHS Facility Logs are reviewed as part of off-site preparation for standard surveys to note: Patterns of injury. Patterns involving a resident victim. Patterns involving a resident/staff perpetrator. Possible inclusion in survey sample.

Facility Log Instructions Facilities are asked to make an initial determination about incidents and decide what is reportable and what is not, in accordance with CMS Regulations. If the facility has a question about whether or not an incident is reportable, they are advised to report. Incidents (and investigation findings) involving any level of harm should be reported to the Bureau’s Complaint Investigation Unit and summarized on the Facility Log. Incidents that do not involve harm should be summarized on the log, only. In all cases, facilities should assess the incident and implement corrective measures, as appropriate. Facilities are to submit this form to their Licensing Officer by the 15 th of the month, or more frequently, as directed. The Licensing Officer will review the log and may contact you with additional questions or for copies of investigational materials. Facilities should complete an internal investigation on each event. Information should include documentation that supports a summary statement of the event, conclusions reached and evidence of corrective action initiated, if appropriate. The Licensing Officer will determine what additional follow up or on-site surveyor investigation will be necessary. UpNorth Team Phone:(989) Fax: (989) Metro West Team Phone:(313) Fax: (313) Metro East Team Phone:(313) Fax: (313) Mid-Mich Team Phone:(517) Fax: (517) Southwest Team Phone:(517) Fax: (517)

BHS Facility Log -- Expectations Complaint Team surveyors will review the BHS Facility Logs completed since the last standard survey for entries relevant to the complaint/facility reported incident under investigation. Standard Survey Team will review on-site the log entries since the last report.

BHS Facility Log -- Expectations As part of discretionary review, (between standard surveys) Licensing Officers may: Require a Plan of Correction to address an incident. Request copies of reports or documents related to FRI. Request a voluntary in-service. Initiate a State Monitoring visit. Require immediate reports and 5 day investigation reports for all alleged abuse, neglect, and mistreatment incidents.

7 KEY COMPONENTS ( Detection/Prevention)  Prevent  Protect  Screen  Report/Investigate  Identify  Respond  Train

PREVENT The provider has the capacity to prevent the occurrence of abuse and neglect and reviews specific incidents for “lessons learned” which form a feedback loop to affect policy change.

PREVENT (CONT.) Mission statement: Goals, values, vision. and a guiding principle. Policies/Procedures: ~ Abuse and neglect ~ Individual/family rights and responsibilities ~Admission/discharge ~ Assessment/care planning ~ Clinical protocols

PREVENT (CONT.) Monitoring: Review of individual complaints Satisfaction surveys (resident/family/staff) Problem identification program Staff competencies Clinical outcomes Process

QUALITY IMPROVEMENT Periodic review/revision of policies/procedures Monitoring activities Analysis of incidents Satisfaction surveys Review of incident reports Identification of trends

Facility Self- Check Application of Federal definitions Effective program planning, implementation, monitoring, and quality improvement Is your approach to managing this issue understood by the appropriate parties? Clear understanding of what to do if abuse/neglect occurs Resident, staff, advocates, can identify S/S of abuse/neglect

FACILITY SELF-CHECK Policy and Procedure Manual containing: Mission statement, P/P for the various form of abuse/neglect,complaint file,incident reports, and a review of process outcome documentation Problem Identification Process/System: Consideration of staff competencies, report tracking and identification of trends, outcome tracking, and evaluation of organizational processes, including compliance. What methods/approaches for detecting/preventing abuse/neglect have been instituted since last survey? What were the outcomes?

FACILITY SELF-CHECK Mission of organization? Process for reporting abuse/neglect, theft of resident property, injuries to resident? Staff demonstration of knowledge, skill, ability to assess, plan, respond, & evaluate resident needs as a continuous process, support QOL/Quality care?

SCREEN Facility screens for any previous history of A/N against prospective employees. Facility screens for employee’s experience in working with the population. Facility makes sure the needs of the resident can be met by the facility prior to admission.

Screen: Detecting Abuse/Neglect Why did this happen? Could it have been prevented? Did I overlook something in the hiring process? Do we need to revise our screening process?

IDENTIFY The provider creates and maintains a proactive approach for identifying events and occurrences that may contribute to A/N

Is your facility at risk? Staff characteristics Administrative structures Staffing patterns Resident characteristics TraditionWages Facility environment Communication patterns Support systems

TRAIN Employee reporting requirements Procedures for detection, intervention, prevention Resident/advocate trained re: identification of S/S of A/N

PROTECT The provider protects individuals from abuse during investigation of any allegations of abuse and neglect.

Report & Investigate Any employee who suspects or witnesses abuse or neglect toward a resident must report it (immediately) to a facility administrator or his/her designee. The provider ensures that any suspected or alleged incidents of A/N are investigated quickly, thoroughly, and objectively. Report substantiated incidents to state and local law enforcement and regulatory agencies as required.

Priority “1” Exceptions Injury or incident involving a death or potential criminal activity under investigation by a state or local law enforcement agency. Abuse with injury Elopement of a resident missing for more than 2 hours Serious injury which is life-threatening to resident Sexual assault An allegation of failure to readmit a Medicaid resident

RESPOND The provider assures that the appropriate corrective, remedial, or disciplinary action occurs in accordance with applicable local, state, or federal law

REFERENCES Abuse Prohibition Review Survey Checklist: MDCIS BHS Complaint and Facility Reported Incident Manual (Rev. April 20, 2005) CMS (HCFA Staff) Mike Dankert, Director, Bureau of Health Systems (2006) State of Michigan Nursing Homes and Nursing Care Facilities Rules State Operations Manual To obtain training materials, Michigan facilities may contact: HCAM and MAHSA