Protecting Patients from Abuse and Neglect

This is an organization-wide policy. It applies to all care settings and services.

To define the mechanism by which patients will be protected from abuse and neglect while under the organization’s care and service.

To provide guidelines surrounding suspected or confirmed instances of abuse and/or neglect.

Abuse: The willful infliction of physical or mental injury, unreasonable confinement, intimidation, or punishment that results in pain, physical or mental harm, or mental anguish.

Child/Youth: A person under 18 years of age.

Exploitation: The unreasonable use of an older person or person with a developmental disability in order to obtain control or to divert to the advantage of another the ownership, use, benefit or possession of or interest in the person’s money, assets, or property by means of deception, duress, menace, fraud, undue influence or intimidation.

Neglect: A failure, through inattentiveness, carelessness, or other omission, to provide goods and services, such as adequate healthcare, necessary to avoid physical harm, mental anguish, or mental illness.

Older Person/Elderly: A person who is at least 60 years of age.

Person with a developmental disability: A person 18 years of age or older who has a developmental disability.

Vulnerable populations: Include but are not limited to youth/children, persons with developmental disabilities, and elderly person over the age of 60.

The organization will make all reasonable efforts to protect patients from abuse and neglect while under our care and service. To that end, the following policy is
established:

ALLEGATIONS OF ABUSE BY STAFF
The staff member(s) in question will be reassigned to non-patient care duties and shall have no contact with patients until the investigation is concluded. A representative of the organization will meet with the patient and/or family (decision-maker) and – to the extent permitted by hospital policy and law – keep the patient informed as to the status / outcome of the investigation.

POTENTIAL ABUSE BY FAMILY OR VISITORS
Access to the patient by identified family / visitors will be restricted or prohibited depending on the situation. Security and Nursing Staff will be made aware of the potential for an abusive situation and will – if necessary – screen the family / visitors and/or monitor the patient frequently during times these individuals are in attendance.

INVESTIGATION AND REPORTING OF POSSIBLE ABUSE & NEGLECT
Any potential incident of abuse or neglect will be investigated by the organization and reported to the appropriate State authorities immediately in accordance with hospital policy.

Under Washington state and federal law, WhidbeyHealth is a mandatory reporter of suspected or confirmed instances of abuse and/or neglect. People who are victims of abuse or neglect may seek treatment for a variety of reasons and by assessing and reporting patients who may be victims of abuse, there is an opportunity to protect individuals from harm. The WhidbeyHealth care team member who suspects abuse and/or neglect must report the same to the appropriate enforcement agency.

1. All WhidbeyHealth staff who have direct patient care responsibilities will receive annual education regarding abuse and neglect. This education will include recognizing symptoms of abuse, assessing victims of abuse, and the appropriate mechanisms for reporting abuse.

2. Possible victims of abuse and/or neglect are identified by WhidbeyHealth staff in the following categories:

• Physical assault or abuse
• Rape, sexual abuse or other molestation
• Mental, verbal or emotional abuse
• Domestic abuse/violence
• Exploitation

3. General criteria for suspicion of abuse or neglect:

• Report by the patient or others of abuse or neglect
• Inconsistencies with physical evidence and verbal report of injury, e.g., x-rays show unexplained fracture of bones, bruises in various stages of healing, etc.
• Unexplained injuries, bruises, contusions, lacerations, scars, burns, fractures, injuries during pregnancy, multiple injuries, etc.
• Discrepancies in injury history as provided by the patient or others knowledgeable
• Implausible history or explanations
• Delay in seeking medical care
• Evidence of physical assault, rape, or sexual molestation
• Physical findings consistent with neglect, including but not limited to poor nutritional status, poor physical hygiene, failure to thrive, delay in seeking appropriate medical evaluation or treatment.

4. Competent adult victims of sexual assault and intercourse without consent should be encouraged to file with law enforcement (this is not a mandatory report for clinical but based on patient decision). Victims of these crimes should be strongly encouraged to immediately report to law enforcement but ultimately it is their decision to make.

5. Suspected or confirmed abuse or neglect of vulnerable populations must be immediately reported by the WhidbeyHealth care team member who detects it to the appropriate reporting agency as required by state law:

• Child Abuse Hotline: 1-866-363-4276 (1-866-ENDHARM), available 24/7
• Adult Protective Services Abuse Line: 1-866-363-4276 (1-866- ENDHARM), available 24/7 or 509-225-4412, available during normal business hours
• If the person is also a resident of a long-term care facility, report the matter to the Long-term Care Ombudsman at 1-800-562-6028, available during normal business hours
• Local Law Enforcement

6. An immediate referral should be made to the Social Worker following the initial phone call to the appropriate agency listed above.

7. WhidbeyHealth will not employ persons who have been convicted of abusing or neglecting individuals.

8. Allegations of abuse or neglect inflicted on a patient by WhidbeyHealth staff are to be promptly investigated and the following completed, if possible:

• Department Manager is to be notified immediately by phone call and if unavailable call the Administrator on Call (AOC).
• Event report created by the WhidbeyHealth staff person receiving the complaint must immediately be filed after Manager or AOC notification.
• Manager or AOC will notify Human Resources during business hours immediately following notification of abuse allegation.
• Quality may assist with gathering information from the patient or
  eyewitnesses.
• Documentation that the victim was examined properly for injury and results of the examination.
• Steps will be taken immediately to protect the alleged victim from further alleged abuse until investigation is complete.
• Corrective action taken and documented to prevent further abuse.
• Notification of licensing agencies by the Director and Human Resources.

CMS Medicare Conditions of Participation: §482.13(c) (3)