O TIS Reporting Requirements Conducting a Thorough Abuse/Neglect Investigation

1. OTIS Reporting RequirementsConducting 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 • F-225 • 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, Misappropriationof 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 • “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 • F-224 • 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! LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS • 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

31. Is This Resident Capable of Willful Infliction of Injury with Intent to Harm? ↙ ↘ YESNO ↓↓ Injury?? Injury?? ↙ ↘ ↙ ↘ No Injury or SeriousNo Injury orSerious Non-Serious Injury InjuryNon-Serious Injury Injury ↓↓ ↓ ↓ Do NotInvestigateSystem 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 • Law enforcement (CMS S&C memo, 6/17/2011) • APS • NAT-7 • Nursing Board • Health Standards • Sheriff’s office, Ag’s office • APS • 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

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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, GinkoBiloba, Vitamin E and Fish Oil LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS/Health Standards Section

46. HSS Processes • Initial review by PM • 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 email, fax or telephone • Denise.Traylor@LA.GOV • Lizzie.Armstrong@LA.GOV • 225-342-0453 (fax) • 225-342-7715 (Denise), 225-342-5795 (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