DETECTION AND PREVENTION OF ABUSE AND NEGLECT

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DETECTION AND PREVENTION OF ABUSE AND NEGLECT

• Quality Improvement Nurse Consultants

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BACKGROUND INFORMATION

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

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RULES AND REGULATIONS

• The Feds say
• Report, report!!
• Investigate and---
• Report again!!

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Where do you find the Federal Requirements?

• CFR 483.13 (c) (1) (iii)
• CFR 483.13 (c) (2)
• CFR 483.13 (c) (3)
• CFR 483.13 (c) (4)

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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

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STATE OF MICHIGAN LAWS

• M Tag 0090 Section 21771- (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.

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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 patients representative, or
  an employee who makes a report under this section

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STATE OF MICHIGAN LAWS

• Section 21771 also requires the reporting of
  other occurrences which threaten the welfare,
  safety, or health of residents, such as
• 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.
• 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.
• 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.

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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

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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

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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

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WHAT TO LOOK FOR? (CONT.)

• Malnutrition
• Contractures
• Pressure Ulcers
• Certain psychosocial behaviors

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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

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Incidents-Involving Harm

• Are to be reported immediately to the Bureau of
  Health Systems (BHS)
• BHS-OPS-362 24 Hour Report Completed
• Recorded on BHS Facility Log
• Investigation commences, while residents are
  safeguarded

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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

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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

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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.

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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.

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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 Bureaus 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 15th 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 [phone] Fax (989)
  732-8958
• Metro West Team Phone [phone] Fax
  [phone]
• Metro East Team Phone [phone] Fax
  [phone]
• Mid-Mich Team Phone [phone] Fax (517)
  334-8473
• Southwest Team Phone [phone] Fax (517)
  334-8473

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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.
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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.

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7 KEY COMPONENTS(Detection/Prevention)

• ? Prevent ? Protect
• ? Screen ? Report/Investigate
• ? Identify ? Respond
• ? Train

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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.

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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

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PREVENT (CONT.)

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

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QUALITY IMPROVEMENT

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

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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

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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?

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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?

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SCREEN

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

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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?

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IDENTIFY

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

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

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

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PROTECT

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

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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.

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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

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RESPOND

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

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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