Abuse Allegation & Abuse Reporting

1. Abuse Allegation & Abuse Reporting

2. Abuse Allegation

3. Objectives After completion of the module, the employee will be able to: • 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 in relation to abuse allegations • Identify time frame for abuse reporting

4. 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

5. Procedure

6. 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 harassment 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

7. 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

8. Reporting & Notification 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 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

9. 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

10. 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

11. 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”)

12. 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.

13. Other Important Roles

14. 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

15. 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

16. 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

17. 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

18. 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

19. Abuse Reporting

20. Mandated Reporter “FYI” for the Mandated Reporter • Reporting is the individual responsibility of the mandated reporter. No physician, supervisor or administrator may prohibit the filing of a required report. • The law provides civil and criminal liability protection for anyone who makes a report in good faith. • Reports made under this law are confidential. The identity of all persons making reports of abuse is also confidential. • All mandated reporters are required to sign statements with their employers or with the State agency issuing their license of certificate. These statements confirm knowledge of the reporting requirements and agreement to comply with the law.

21. Filling a Report • Reports of suspected child abuse are to be called immediately to child protective agency or local law enforcement and follow-up written reports must be sent within 36 hours. • Reports of adult/elder abuse are to be called immediately or as soon as possible to local long term care ombudsman or local law enforcement agency and follow-up written reports must be sent within two working days (48 hours). • The appropriate written report (see attachments) is to be filled out completely and legibly. This form may also be used instead of a telephone report to make a voluntary report of mental abuse, financial abuse, neglect, isolation, or abandonment of an elder or a dependent adult/child by that person’s caretaker. • The written report is to be hand delivered to the Case Management office for centralized tracking and mailing. (This must be completed within 48 hours).

22. Filling a Report Reports must include the following information, unless unavailable: • The name, address, telephone number and occupation of the person making the report. • The name and address of the patient. • The date, time and place of the incident. • Other details, including the reporter’s observations and beliefs concerning the incident. • Any statement relating to the incident made by the patient. • The name(s) of the individual(s) believed to have knowledge of the incident. • The name(s) of the individual(s) believed to be responsible for the incident and their connection to the victim. Clearly document in the progress notes that a report was filed.

23. Abuse Forms