1. Denise Traylor, BSN, RN DHH/Health Standard Section
OTIS Reporting Requirements Conducting a Thorough Abuse/Neglect Investigation
Denise Traylor, BSN, RN
DHH/Health Standard Section
LNHA DON Boot Camp
8/26/2014

2. Conflict of Interest Statement
There is no conflict of interest present for planners and faculty/presenter/authors relative to this educational activity, including financial relationships
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

3. Objectives Discuss regulatory reporting timelines
Define & discuss Abuse, Neglect, Injury of Unknown Origin, Misappropriation of Property, Willful Infliction of Injury with Intent to Harm and their relationship to state & federally mandated reporting in the Online Tracking Incident System (OTIS)
Review & discuss federal regulations governing the reporting of Abuse, Neglect, Injury of Unknown Origin and Misappropriation of Property reporting
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

4. Objectives
Discuss incidents that are and are not reportable in the OTIS system
Discuss appropriate referrals
Discuss the investigation of elopements
Discuss the components of a thorough investigation
Discuss clinical forensic markers to consider in Abuse/Neglect investigations
Discuss Health Standards processes in reviewing OTIS reports
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

5. Reporting Requirements
F-225
All alleged violations are reported immediately to administrator and to other officials in accordance with state law, (including the State survey & certification agency);
The facility must have evidence that all alleged violations are thoroughly investigated, and prevent further potential abuse while the investigation is in progress
the results of the investigation must be reported to the administrator and other officials in accordance with state law (including the State survey & certification agency) within 5 working days of the incident

6. Reporting Requirements
State Minimum Licensure
Immediate verbal reporting and a preliminary written report within 24 hours of the incident to Health Standard Section through OTIS
Appropriate authorities are to be notified according to state law
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

7. Injury of Unknown Origin
Injury of unknown source must meet both of these conditions
Source of the injury not observed by any person, or the source of the injury could not be explained by the Resident
and
the injury is suspicious because of the extent of the injury or the location of the injury (injury located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

8. What in Injury of Unknown Origin Is Not
An Injury of Unknown Origin does not include minor bruises, abrasions, scrapes, etc., that are not suspicious for Abuse.
Injury that is explained by a cognitive Resident
Non-serious injury that is in an area that is not suspicious for Abuse.
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

9. Policies & Procedures F-226
Policies and procedures for screening and training employees, protection of Residents and for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment of Residents and misappropriation of Resident property
Purpose is to assure that the facility is doing all that is within its control to prevent occurrences
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

10. Reporting Requirements
The Discovered date is the point at which any member of your staff becomes aware of an allegation of Abuse, Neglect, Misappropriation of Resident property or Injury of Unknown Origin
Every staff member should be intimately familiar with the Abuse policy and should know how to institute Abuse procedures and immediately protect the Resident
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

11. Abuse
F-223
Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish
Includes deprivation of goods and services necessary to attain or maintain physical, mental or psychosocial wellbeing
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

12. Physical Abuse is Not Staff to Resident Resident to Resident
“roughness” that leaves no injury
Resident to Resident
Non-serious injuries that are not of serious consequence to the individual, such as those that cause discomfort, redness to the skin, minor scratches, superficial lacerations/skin tears, abrasions, minor bruising; pushing or pulling that causes no injury
If there is no injury, there is no physical abuse, unless the incident has potential for serious actual harm (Resident has knife, gun, etc.)
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

13. Verbal Abuse
Use of oral, written or gestured language that willfully includes disparaging and derogatory terms to Residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability
Includes threats of harm, saying things to frighten a Resident
In the OTIS system, this would be reported as Emotional Abuse
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

14. Verbal Abuse Is NOT “rudeness”
“inappropriate” conversations/comments (within reason)
minor cursing
insults
nuisance
offensive remarks
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

15. Mental Abuse
Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation
In the OTIS system, this is reported as Emotional Abuse
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

16. Sexual Abuse
Includes but is not limited to sexual harassment, sexual coercion or sexual assault
In the OTIS system, this is reported as Sexual Abuse
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

17. Involuntary Seclusion
Involuntary seclusion is separation of a Resident from other Residents or from her/his room or confinement to her/his room with or without roommates, against the Resident’s will or the will of the Resident’s RP
In the OTIS system, this would be reported as Emotional Abuse
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

18. Involuntary Seclusion is NOT
Emergency or short term monitored separation from other Residents, if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan or care to meet the Resident’s needs
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

19. Caregiver Neglect
F-224
Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

20. Caregiver Neglect Is Not
Acts of inefficiency, unsatisfactory conduct, failure in good performance
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

21. Misappropriation of Resident Property
Deliberate misplacement, exploitation or wrongful, temporary or permanent use of a Resident’s belongings or money without the Resident’s consent
The law does not specify a dollar amount or value
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

22. Willful Infliction of Injury with Intent to Harm
“determination of abuse requires that the incident under investigation must have been willful and/or deliberate. If the perpetrator of the incident is demented, willfulness cannot be established.” (Regional S&C letter, 1/20/2000)
“If the Resident decision-making skills are impaired, the Resident’s actions cannot be considered willful, and the Resident cannot be held accountable.” (Regional S&C letter, 1/20/2000)
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

23. Is the Resident Capable of Willful Infliction of Injury with Intent to Harm?
BIMS
Cognitive skills for daily decision making
Diagnoses
Dementia
Alzheimer’s disease
Psychotic disorders
Bipolar
Traumatic brain injury
Input from nursing staff, CNAs, therapists, etc.
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

24. Incidents between Cognitively Impaired Residents
Cognitively impaired Resident cannot be named as the Accused if determined they cannot be held accountable for their actions
Investigate as allegations of Caregiver Neglect; Accused unknown unknown, Relationship staff, Title administrative staff
Evaluate systems in place to protect Residents
Were systems actively in place to ensure safety
Were Residents being supervised according to care plans?
Are care plan approaches appropriate?
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

25. Serious Injury
Bodily injury which involves substantial risk of death, protracted and obvious disfigurement, or protracted loss or impairment of the function of a body member or organ, or mental faculty.
More than a minor cut, bruise or superficial skin tear.
Reduces the Resident’s appearance, value, usefulness etc., and impairs the function or condition of the Resident.
Has some connotations of permanence.
May be physical, mental or psychological.
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

26. Non-Serious Injury
Any injury determined not to be serious by the appropriate medical personnel who assessed the Resident.
Includes: discomfort, superficial lacerations, skin tears, abrasions, minor bruising, etc.
May involve insult, nuisance and offence.
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

27. What is Not Reportable Resident to Resident incidents without injuries
Non-serious Injuries
Small bruises, skin tears
Minor injuries not of serious consequence
Injuries that cause discomfort, redness to the skin, minor bruising, scratches, superficial lacerations, skin tears, abrasions
Insult, disrespect, nuisance, offence, minor cursing
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

28. What is Not Reportable Resident to staff or visitors
Injury of Unknown Origin
Explained by Resident
Cognitive Resident states not from Abuse/Neglect
Non-serious Injury
Not in an area suspicious for Abuse
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

29. What is Not Reportable
Minor occurrences which are not of serious consequence to the individual
should be recorded by the facility according to their policies and procedures for incident recording, investigation and tracking.
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

30. PLEASE NOTE!
Residents involved in multiple incidents triggers at survey
Ensure that approaches in the care plan are appropriate
Ensure that staff are educated and approaches are being followed
Consider if there is adequate staff to supervise and monitor Residents
Monitor through QA tracking program
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

31. Is This Resident Capable of
Willful Infliction of Injury with Intent to Harm?
↙ ↘
YES NO
↓ ↓
Injury?? Injury??
↙ ↘ ↙ ↘
No Injury or Serious No Injury or Serious
Non-Serious Injury Injury Non-Serious Injury Injury
↓ ↓ ↓ ↓
Do Not Investigate System Failure?? Investigate
Report Abuse ↙ ↘ Caregiver Yes No Neglect
↓ ↓
Investigate Do Not Report 
Caregiver Neglect
HSS-HN-17 (Origin 11/2011) Health Standards Section
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

32. Referrals Facility Health Standards
Law enforcement (CMS S&C memo, 6/17/2011)
APS
NAT-7
Nursing Board
Health Standards
Sheriff’s office, Ag’s office
Nursing board and other licensing boards
CNA desk
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

33. Elopements
Resident who is an elopement risk leaves the premises or a safe area without authorization &/or necessary supervision
Investigate as Caregiver Neglect; Accused unknown unknown, Relationship staff, Title administrative staff (unless 1-on-1)
Was there a system failure?
Did the Resident elope because of lack of supervision?
Was the Resident being supervised according to care plan?
Were care plan interventions appropriate?
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

34. Thorough Investigation
Facilities can best support the detection and prevention of abuse and neglect by establishing and facilitating policies and procedures that reinforce the expectation of immediate reporting of suspected abuse and neglect.
Providers should have a process in place that makes it possible for Residents, staff, family members, and advocates to report abuse and neglect in a manner that will elicit immediate attention by the organization.
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

35. Thorough Investigation
All allegations should be treated with the same degree of consideration and seriousness
Thoroughly collecting information and corroborating evidence immediately improves the likelihood of a valid conclusion
Residents and staff should understand the meaning of Abuse/Neglect and their role in Abuse/Neglect reporting
All should feel protected from retaliation
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

36. Thorough Investigation
Drawing a reasonable inference or an assumption about what happened does not negate the requirement for a thorough investigation and reporting of the incident.
The investigator must approach the investigation with an open mind, without jumping to conclusions, or formulating an opinion prior to evaluating all the collected evidence.
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

37. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
STEPS
PROCEDURES
Step 1: Protect the
Resident
Supervisor immediately assesses Resident’s personal safety & potential of harm to other Residents
If caregiver is named, supervisor immediately removes the accused caregiver from the Resident care area (obtain Accused’s statement prior to allowing them to leave the facility)
Notify designated managers of the allegation
Contact RP & physician
Determine if law enforcement should be involved
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

38. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
Step 2:
Assess the Effect
on the Resident
*Nursing supervisor immediately completes an
assessment & documents findings;
*If there is a physical injury, document the size, location, color, pattern, number of injuries, etc.; Include if treatment or medical attention is required & provided
*Lead investigator/nursing supervisor assesses for psychosocial changes & documents findings
*Appropriate medical/psychosocial treatment & support to the Resident is provided
*Evaluate to determine if this incident should be reported in OTIS
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

39. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
Step 3: Investigate
the
Allegation
*Who, What, Where, When, Why & How
*Collect & protect evidence, including any ER, hospital, X-ray, etc. reports
*Obtain written, dated, signed statement from the Accused/s
*Obtain written, dated, signed statements from the Resident/s & the person/s reporting the incident
*Obtain written, dated, signed statements from all
witnesses or any other persons who may have
knowledge or information about this incident;
ensure that statements are as detailed & objective
as possible
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

40. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
Step 3: Investigate the
Allegation (con’t)
*Review all statements for use of vague terms (“rough” treatment, “treated me ugly”, etc.), & obtain clarification
*Review all statements for conflicting information & obtain clarification
*Document any knowledge of bias between alleged
abuser/s, witnesses or Residents
*Review Accused’s work assignment & determine if
Accused was working at the time of the incident; obtain a copy of the Accused’s time card
*Review & consider Accused’s personnel record for history or previous disciplinary actions, accusations, etc.
*Document any Resident outcomes
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

41. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
Step 4:
Conclude
the
Investigation
*Review all components of the investigation
*Determine if the allegations are Substantiated,
Unsubstantiated, or Unable to Verify
*Document any training done as a result of this incident, or systems put in place to ensure that this incident does not re-occur
*Examine facility policies & procedures to determine if any changes are warranted
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

42. LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
Step 4:
Conclude
the
Investigation
*Review all components of the investigation
*Determine if the allegations are Substantiated,
Unsubstantiated, or Unable to Verify
*Document any training done as a result of this incident, or systems put in place to ensure that this incident does not re-occur
*Examine facility policies & procedures to determine if any changes are warranted
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

43. Clinical Forensic Markers
Accidental trauma is usually distal: knees, chin, fingers and toes
Suspicious injuries generally midline and proximal: face, neck, chest, breast, back, buttocks
Sexual trauma: face, neck, arm, chest, breast, back and buttocks
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

44. Fractures
Fractures of the head, spine and trunk are more likely to be assault injuries than limb fractures, sprains or musculoskeletal injuries
Spiral fractures of large bones with no history of gross injury suspicious
Fractures with rotational component suspicious
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

45. ADDITIONAL CONSIDERATIONS
Medications
Aspirin, Warfarin, Ibuprofen, Celebrex, Ketorolac, Heparin, Depakote, Valproic Acid, Prednisone, Plavix
Herbal Supplements
St. John’s Wort, Bilberry, Garlic, Ginger, Ginko Biloba, Vitamin E and Fish Oil
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

46. HSS Processes Initial review by PM Final Review
Referrals to Sheriff’s office, NOPD
Final Review
Return for corrections
Request documentation
Refer to Sheriff’s office, NOPD, AG
RN board, LPN board, CNA desk, other licensing boards (Pharmacy board, Medical board, etc.)
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

47. EXTENSIONS Requests for Extensions
Granted by Denise Traylor, Program Manager or Lizzie Armstrong, Secretary
By , fax or telephone
(fax)
(Denise), (Lizzie)
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

48. OTIS Glitches
When logging into OTIS, you get the message that you must use Internet Explorer when accessing this system:
Click on Tools, Highlight Compatibility View Settings, click on “Display all websites in Compatibility View”. If you continue to get this message, copy the OTIS URL and paste under “Add this website”, and click “Add” located to the right of the blank. The OTIS website should now be in the big box underneath
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

51. OTIS Glitches
Input times in the Events section with no “0” in front: 3:54 pm, not 03:54 pm
Input of the Accused Title often has to be done twice, initially as well as when making corrections
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

52. Senarios
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

53. RESOURCES OTIS Welcome Page OTIS Training Resources
OTIS Training Resources
Located near the bottom of the OTIS Welcome Page
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

54. CONTACT INFORMATION
Denise Traylor – OTIS Program Manager
(phone)
(fax)
Lizzie Armstrong – OTIS Secretary
(phone)
LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section