Abuse Allegations

CapeCodMermaid, RN · Jun 4, 2011

I take every allegation of abuse very seriously.

First if the accusation is made against a specific individual, I suspend them immediately and start investigating. I interview the resident(s) involved, the accused, all the other staff members who might have seen or heard something and then I determine if the allegation is true. Many times it's easy to see that the person is just very confused....'he threw me out the window last night and I landed in the bushes' or 'that black guy kicked me and I'm pregnant by that doctor'. Some allegations can't be proven or disproved. It's not always easy to determine who is telling the truth, but I have a pretty good sense about people and if I believe they have been the least bit abusive, I won't hesitate to fire them. Of course this all gets reported to the DPH.

A word of advice/caution to those who don't investigate: there was a beautiful facility in which abuse was occurring. A small child saw a CNA kick one of the residents. She told the administrator who did nothing because it was a child reporting it. A few days later, someone else reported that they had heard the same CNA screaming at a resident (not a raised voice because the person was hard of hearing, but a mean, threatening scream). Again the administrator did nothing. Finally a third allegation about the same CNA was made. Finally there was an investigation. The CNA ended up going to jail, the administrator lost her license permanently, and the facility almost closed down.

We are charged with keeping our residents safe. Do I like spending time on investigations? No, but it's necessary to make sure the residents we have in our care are not abused. Any director or administrator who doesn't investigate should be fired.

txdon · Jun 4, 2011

I agree. The problem I'm facing is that I believe abuse is occurring and the DON unsubstantiates it. For instance, I had a resident report that a CNA pulled him out of bed while he was sleeping, shoved him, and told him he needs to comb his own hair because she's tired of having to mess with it. The resident also reported this has happened on another occassion as well but after it happened again he felt compelled to report. This was reported to the DON and her response was,"I doubt that happened." I'll talk to him. That's it. This happens all the time and the administrator supports her. It has been made clear to me that she does not want me "investigating" things. She will handle "ALL" investigations. Furthermore, when she does suspend employees when there is an allegation of abuse or neglect, they are usually "unsubstantiated" because the resident feels "safe" or other residents haven't experienced issues with the employee in question. The stories I hear are horrifying. We have had multiple complaints involving allegations of abuse at our facility. Also, when an allegation of abuse is presented she automatically sides with the employee. I'm the opposite. That inferiates her. She has told me she believes I'm trying to throw her under the bus because I won't let things go. Not sure what to do.

Long Term Care Columnist / Guide · Jun 4, 2011

The problem is, you are a mandatory reporter just as the DON and the administrator are, and if YOU fail to report and the state gets hold of it, you're going down with the others. Believe me, it's not worth it!

Five years ago, I received the only write-up of my entire career because I relied on my administrator to report a case of inappropriate sexual touching between residents. I'd reported it to him in a timely manner; unfortunately he didn't take it up the chain of command and report it to APS, and the VP of Operations nearly fired us both when he found out neither of us had reported the incident. Actually, I felt fortunate that the BON never got wind of it, because it could have cost me my license.

Therefore, it would behoove you to report suspected abuse of any kind to APS if you've run it through the proper channels and no one has acted on it. It may mean having to be really assertive and telling TPTB "Look, I'm not going to lose my license over this. If you don't report this to (insert authority here) within 24 hours, I will." Then DO it.

Good luck to you.....Working in a facility where abuse allegations aren't reported, you are going to need it.:kiss

Nascar nurse, ASN, RN · Jun 5, 2011

My state has an online reporting site. You may want to see if your state board of health has the same option.

Had a sweet but very confused little old lady yelling loudly up and down hall that she had been abused. Telling every staff member, resident and visitor in site. Showing her arms to all and saying "just look at what they have done to me" and kept yelling "ABUSE". All this damage to her arms were really just normal old lady skin with the blue veins running like rivers down her arms. She was absolutely convinced that the veins were gouge marks from abuse. No changing her mind and eventually we just played along and gave her the sympathy she was seeking. But, we reported it to the state just the same. These days you just can't afford to be accused of hiding something.

txdon · Jun 5, 2011

Oh my. I thought that since the DON has taken on the responsibility to report all allegations of abuse then she was the one held accountable. Our state does have online reporting, but I have no idea how that is done. I have not been previed to the investigation and reporting process. Like I said in my previous post, we report to her and she reports to the state. How is it decided what needs to be reported. Does anyone have guidelines to follow?

Nascar nurse, ASN, RN · Jun 5, 2011

I'll start, but sure to miss a few. Someone chime in here with me

1. Fall with a fracture on a dependent resident

2. Bruise over 10cm

3. Elopement

4. Choking episode that required evaluation/tx at the hospital

5. 2nd/3rd degree burn

6. Abuse - any kind (we submit all allegations of abuse - even the ridiculous &/or unsubstantiated ones)

7. Resident to resident altercation - physical/sexual

Sunday morning...mind not turned on yet. What am I missing?

My understanding of the rules (at least in my state) is that the administrator MUST be made aware of any situation and should be the reporter if available. As DON/ADON, I have frequently reported in the absence of the administrator but ALWAYS call them and make them aware.

I would caution you to make sure your administrator/DON is aware before you start reporting. As someone who would do it right, I would be beyond furious if someone started reporting to the state without notifying me first.

CapeCodMermaid, RN · Jun 5, 2011

I report to DPH:

* fall with fracture on any resident even if they are independent with everything.

*If someone is alert and oriented x3 and is their own person, I usually don't report if they leave the building...my residents are mostly younger and just like to break rules. If they are incompetent/demented I report if they leave the building.

*Any fall which requires a trip to the hospital unless it is clearly witnessed to have been caused by a medical event...had a guy have a massive MI and down he went.

*resident to resident altercations

*allegations of abuse unless they are totally unbelievable such as 'everyone in this building had sex with me last night'

I always let the administrator know if I'm reporting something and I always send a copy of the report to corporate.

I keep a copy of the report, the fax confirmation, the witness statements (if any),and the incident report in a file in case the state comes out on the report so everything is in one place.

txdon · Jun 5, 2011

I my State they publish all occurances on the state's website. Does numerous reporting result in a negative mark on the facility?

Nascar nurse, ASN, RN · Jun 5, 2011

I my State they publish all occurances on the state's website. Does numerous reporting result in a negative mark on the facility?

Are they really posting all occurances or just the substantiated complaints?

As far as numerous reports my surveyors made it very clear a year or so ago that we would be in WAY more trouble for NOT reporting something that should have been in their opinion. Note the "their" opinion, ie: better to over report.

And to CCM, we also report all fractures but the official wording for my state includes the "dependent resident" part. Dependent is determined by the coding on the most recent MDS.

txdon · Jun 6, 2011

Yes, all occurances are posted on the state's website. It describes whether or not the allegations were substantiated and what actions were taken if any.

debRN0417 · Jun 8, 2011

Here are the regulations (not all of it)

F225:

The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).

The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.

The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

F226:

Use F226 for deficiencies concerning the facility's development and implementation of policies and procedures.

Intent: 483.13©

The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences.

Guidelines: 483.13 ©

The facility must develop and implement policies and procedures that include the seven components: screening, training, prevention, identification, investigation, protection and reporting/response. The items under each component listed below are examples of ways in which the facility could operationalize each component.

I. Screening (483.13©(1)(ii)(A)&(B): Have procedures to screen potential employees for a history of abuse, neglect or mistreating residents as defined by the applicable requirements at 483.13©(1)(ii)(A) and (B). This includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries.

II. Training (42 CFR 483.74(e)): Have procedures to train employees, through orientation and on-going sessions on issues related to abuse prohibition practices such as:

- Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents;

- How staff should report their knowledge related to allegations without fear of reprisal;

- How to recognize signs of burnout, frustration and stress that may lead to abuse; and

- What constitutes abuse, neglect and misappropriation of resident property.

o Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. (See 483.10(f) for further information regarding grievances.)

o Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes an analysis of:

- Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility;

- The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs;

- The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds; and

- The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff.

o Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation.

o Investigate different types of incidents; and

o Identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. (See 483.13 ©(2), (3), and (4).)

o Protect residents from harm during an investigation.

o Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation;

o Report to the State nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; and

o Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences.

EVERY facility is REQUIRED by the regulations to have a procedure and policy for handling abuse, neglect, and misappropriation allegations and the investigation process. This should be available to all employees and not a secret known only to the DON and administratior. All licensed staff are MANDATED reporters and have the legal obligation to FIRST protect the person who is the alleged victim, and then investigate, and report.

This is a serious issue that is looked at carefully by the regulatory agencies- not just the "State" but the Ombudsman, Department of Social Services, Adult Protective Services, and the Office of the Attorney General and Inspector General, as well as CMS. All facility reported incidents are reviewed carefully by the state agency and CMS. At every survey the Administrator is asked if the facility has had any allegations of abuse, misappropriation, or neglect since the last survey and then the documents/reports are reviewed. In my state we examine ALL the documentation of the investigation - not just the written letter of the outcome. We are required to validate the investigation process and that the facility is ensuring that every allegation is thoroughly investigated and reported.