1. ALLEGATIONS OF ABUSE
Internal Occurrence Reporting and Investigation

2. Objectives
After completion of the module, the employee will be able to:
Define abuse and neglect
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 for

3. Introduction

4. Purpose
To provide guidelines and a chain of command for CHSB staff to immediately report any allegation made by a patient or visitor of physical, sexual or other misconduct
To assure timely notification of appropriate licensing and regulatory agencies to protect patient safety and employee rights

5. Definition
Abuse
Willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish
Includes staff neglect or indifference to infliction of injury or intimidation of one patient by another
neglect – failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness

6. 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

7. Procedures

8. 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 harrassment 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

9. 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

10. Reporting & Notification
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
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

11. 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

12. 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

13. 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”)

14. 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.

15. Other Important Roles

16. 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

17. 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

18. 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

19. 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

20. 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

21. Training
All employees will be provided with information regarding abuse and neglect, and related reporting requirement including prevention, intervention and detection
This training will be provided during orientation and through an ongoing training program