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Mandatory Reporter
The EJA requires persons (“Covered Individuals”) including the owners, operators, managers, employees, contractors and agents of long-term care facilities such as nursing homes to report all cases where they have a reasonable suspicion that a crime has occurred against a resident or person receiving care from the facility.
F600 483.12
What is freedom from Abuse, Neglect, and Exploitation
Report the results of all investigations
What is the administrator or his or her designated representative (Abuse Prevention Coordinator)
Abuse Prevention Coordinator
What is the facility Administrator
Number of days to complete a thorough investigation
5 days
Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than
2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
Report the results of all investigations officials in accordance with State law, including to the State Survey Agency
5 days
CMS defines an incident as..
any unexpected or unintentional incident, which results or may result in injury or illness to a resident.
Definition of Exploitation
What is taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion.
Definition of Neglect
What is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
Definition of Abuse
What is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.
Definition of Exploitation
What is taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion.
Definition of Injuries of unknown source
What is source of the injury was not observed by any person; and could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury
Definition of Involuntary seclusion
What is a separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident’s will, or the will of the resident representative.
Definition of Misappropriation of resident property
What is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident’s property or money without the resident’s consent.
If an event occurs, the facility will follow the 5 “I’s” in an effort to minimize the potential for recurrence.
What is..
1. Incident (what happened or was reported as happening)
2. Injury (provide care and document the injury)
3. Interview (who saw the resident last or at the time of the event)
4. Investigate (why did it happen)
5. Intervention (what mitigation effort are we using)
Identified “Never Events” are as follows:
What is..
1. Invasive Procedure Events –
a. Procedure performed on the wrong resident
b. Wrong procedure rendered on a resident
2. Patient Protection Events –
a. Elopement that results in serious injury or death
b. Suicide of a resident
c. Attempted suicide or self-harm that results in serious injury
3. Care Management Events –
a. Medication error resulting in serious injury or death
b. Fall that results in serious injury (e.g., fracture, head injury) or death
c. Facility acquired stage III, stage IV, or unstageable pressure ulcer
4. Environmental Events –
a. Burn that results in serious injury or death of a resident
Mandatory Reporter
What is the EJA requires persons (“Covered Individuals”) including the owners, operators, managers, employees, contractors and agents of long-term care facilities such as nursing homes to report all cases where they have a reasonable suspicion that a crime has occurred against a resident or person receiving care from the facility.
The following methods to ensure the protection of residents during an investigation may include but are not limited to;
What is..
1. Responding immediately to protect the alleged victim and integrity of the investigation.
2. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed.
3. Immediate notification of the alleged victim’s practitioner and the family or responsible party.
4. Removal of access by the alleged perpetrator to the alleged victim and assurance that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents.
5. Notification of the alleged violation to other agencies or law enforcement authorities.
6. Evaluation of whether the alleged victim feels safe and if the he/she does not feel safe, taking immediate steps to alleviate the fear, such as a room relocation, increased supervision, etc.;
a. Providing emotional support and counseling to the resident during and after the investigation, as needed.
b. Protection from retaliation.
7. Monitor the alleged victim and other residents at risk, such as conducting unannounced management visits at different times and shifts.
Definition of Sexual abuse
What is non-consensual sexual contact of any type with a resident.
Factors that may precipitate abuse/neglect/exploitation, including but not limited to...
What is...
a. Signs of staff burnout, frustration, and stress;
b. Staff prejudices to age, culture, race, religion, and sexual orientation;
c. Gender differences; and
d. Negative attitudes toward working with individuals with disabilities
Resident and/or Resident Representative will be educated on facility policies and procedures for the protection of residents and investigation of alleged abuse and neglect through, but not limited to, the following venues:
What is..
a. Family meetings and family nights
b. Facility newsletter
c. On admission
d. Resident care conference
e. Resident/family council
f. Individual conferencing
Residents have the right to be free from..
What is abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.
Procedures in place to provide protection for the health, welfare and rights of each resident residing in the facility. These procedures include, but are not limited to, the following seven components:
What is..
1. Screening
2. Training
3. Prevention
4. Identification
5. Investigation
6. Protection
7. Reporting and Response
According to the National Quality Forum, events in medical care that are clearly identifiable, preventable, and serious in their consequences for patients.
What is Never Events