Title: Abuse and Neglect, Guidelines for Suspicion of. Section: Patient Care Number: RI-002 Pages: 10. Approval SVH Policy and Procedure Committee

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1 Title: Abuse and Neglect, Guidelines for Suspicion of Approval SVH Policy and Procedure Committee Approval Director, Care Management Section: Patient Care Number: RI-002 Pages: 10 Date of Origin: 3/06 Reviewed/Revised Date: 11/11 Next Review Date: 11/13 Approval: MEC 11/14/11 DEFINITIONS: Child Any person up to the age of 18 years who is not emancipated. Independent adult A mentally competent person of at least 18 years of age or a mentally competent child who is emancipated. Dependent adult A person who is at least 18 years of age and is legally, physically, or mentally dependent on another or there is reasonable information to believe that they are physically or mentally dependent on another. Older person Any person 60+ years of age. Abuse Can include any of the following: Physical Abuse Aggressive behavior that causes physical injury to the body. Physical abuse may include but is not limited to lacerations, bruises, minor or major burns, poisoning, internal injuries, sprains, fractures, dislocations, brain damage, subdural hemorrhage, and skull fracture. Emotional Abuse Intentional berating or disparaging behavior toward an individual that negatively impacts that person s emotional well-being. Emotional abuse may include threats of physical abuse. Sexual Abuse Physical attack on sexual organs or forced or coerced sexual activity often accompanied by violence or threat of violence. Neglect - The failure of a guardian, an employee of a public or private residential institution, facility, home or agency or any other person legally responsible to provide food, shelter, clothing or services necessary to maintain the physical or mental health of a person. Domestic Abuse Any form of abuse that involves a spouse, former spouse, live-in, patients or children. Exploitation - The use of a person, his money or his property for the advantage of another by means of duress menace, fraud or undue influence. POLICY: 1. St. Vincent Healthcare (SVH) complies with Montana law requiring healthcare providers who know or have reasonable cause to suspect that an older person, a dependent adult, or a child has been subjected to abuse or exploitation, to report the matter promptly to the appropriate agency. 2. Domestic abuse of an independent adult is reported to law enforcement authorities only at the request of the victim, unless a gunshot or stabbing has taken place, in which case a report must be made to a law enforcement officer immediately., A written report shall be submitted to the law enforcement officer by regular mail within 24 hours after the initial treatment or observation of the wound 3. Whenever a patient seeks health care, and the healthcare provider suspects that partner or family member assault has occurred, the healthcare provider, outside the presence of the suspected offender, may advise the suspected victim of the availability of a shelter or other services in the community and give the victim immediate notice of any legal rights and remedies available. When advice is given it must include furnishing the suspected victim with a copy of MR-1552 (Notice of Legal Rights/Remedies for Assault). 4. If the potential for continued harm or neglect of the patient is identified within the hospital setting, the healthcare professional takes reasonable measures to reduce risk to the patient and SVH staff. This can be accomplished through close monitoring, one to one care, and restriction of visitors and in extreme cases, use of SVH Public Safety officer or police officers. The Department Director, Administrator on Call Human Resources and Risk Management is notified to assist with the investigation or support the process. 5. All staff is obligated to report any suspicion of abuse, neglect, or exploitation by accessing the proper chain of command process. 6. The following departments can be utilized by staff as additional resources regarding abuse issues: Care Management Department daily Spiritual Care Department weekdays (on call through the Patient Flow Specialist all other times)

2 Abuse and Neglect, Guidelines for Suspicion of RI-002 Page 2 of 11 PROCEDURE FOR REPORTING CHILD 1.1 Observes objective data that indicates a possibility of neglect and/or abuse (see Appendix A). 1.2 Secures immediate patient safety. 1.3 If an employee of St. Vincent Healthcare is involved; an immediate investigation into alleged complaint is started. Notifies supervisor immediately and removes the employee from the person alleging complaint. Supervisor contacts Human Resources 1.4 Reports findings to the Department of Family Services. ( or 911) 1.5 Documents observations factually and objectively in the patient s electronic record. Includes documentation of notification to RN, Provider, Department of Family Services as needed. If the person observing the abuse does not have charting privileges, a healthcare provider with charting privileges documents (using quotation marks) the above and includes the name of the observer. 1.6 Completes Patient Safety Event Report. OLDER PERSON/DEPENDENT ADULT 2.1 Observes objective data that indicates a possibility of neglect and/or abuse (see Appendix A). 2.2 Secures immediate patient safety. 2.3 If an employee of St. Vincent Healthcare is involved, an immediate investigation into alleged complaint will be started. Notifies supervisor immediately and removes the employee from the person alleging complaint Supervisor contacts Human Resources. 2.4 Reports findings to the Department of Family Services ( or 911) for Long Term Care Reporting, additional reporting is necessary, (see Appendix C). 2.5 Documents observations factually and objectively in the patient s electronic record. Includes documentation of notification to RN, Provider, and Department of Family Services as needed. If the person observing the abuse does not have charting privileges, a healthcare provider with charting privileges documents (using quotation marks) the above and includes the name of the observer. 2.6 Completes Patient Safety Event Report. DOMESTIC 3.1 Observes objective data that indicates a possibility of neglect and/or abuse (Appendix A). 3.2 Secures immediate patient safety. 3.3 If an employee of St. Vincent Healthcare is involved, an immediate investigation into alleged complaint is started. Notifies supervisor immediately and removes the employee from the person alleging complaint. Supervisor contacts Human Resources 3.4 Reports to the individual s RN and/or Provider 3.5 Reports findings as follows: Obtains consent from the individual to report other incidents Reports other incidents to law enforcement authorities, if permission is granted. 3.6 Informs patient option of confidential admission status if admitted. 3.7 Documents notification of Provider and/or police and all other reporting action(s) that took place in the patient's medical record. If the person observing the abuse does not have charting privileges, a healthcare provider with charting privileges documents (using quotation marks) the above and includes the name of the observer. 3.8 Advises the suspected independent adult victim of the availability of a shelter or other services in the community. Phone numbers and agencies are available from Care Management. 3.9 Offers the suspected victim Notice of Legal Rights and

3 Abuse and Neglect, Guidelines for Suspicion of RI-002 Page 3 of 11 Remedies MR-1552 (see Appendix B) along with a copy of the Family Violence Resource Handbook. Reads "Notice of Legal Rights and Remedies for Assault" to the patient. Asks the patient to signs and date the "Notice of Legal Rights and Remedies for Assault Gives the original copy of MR-1552 and the Family Violence Resource Handbook to the patient. Scans copy in the electronic medical record Documents in electronic medical record whether patient accepts or refuses information provided Completes Patient Safety Event Report.

4 Abuse and Neglect, Guidelines for Suspicion of RI-002 Page 4 of 11 APPENDIX A Criteria for the Identification of Victims of Abuse CHILD ABUSE Type of Abuse Physical Criteria Behavioral Criteria Physical Neglect Failure to thrive Dull affect, inattentive Signs of malnutrition Excessively passive / sleepy Poor personal hygiene Dirty/inappropriate dress Older Child Evidence of poor healthcare, i.e., immunization status not up to date, untreated infections Stealing / begging for food Absenteeism from school Frequent injuries from lack of supervision Drug / alcohol use / addiction Emotional Abuse or Neglect Failure to thrive Feeding disorders Enuresis Sleep disorders Vandalism / shoplifting Self-stimulating disorders, e.g., biting, rocking, sucking During infancy, lack of social smile and stranger anxiety Withdrawal Antisocial behavior (destructiveness, stealing, cruelty) Extremes in behavior (overly compliant and passive or aggressive and demanding) Lags in emotional and intellectual development Suicidal attempts Physical Abuse Injuries which are unexplained or explanation is inconsistent with medical findings. Bruises and welts On lips, mouth, torso, back, buttocks, thighs Patterns, descriptive of object used, e.g. belt buckle, hand, squeeze/pinch, wooden spoon, chain, rope Present in various stages of healing Burns On soles of feet, palms of hands, back, buttocks, pattern descriptive of object used, e.g. cigarette, glove like from immersion in scalding water, coils from stove Absence of splash marks and presence of symmetric burns Present in various stages of healing Fractures, dislocations Skull, nose, facial structures Injury denotes type of abuse, e.g. spiral fracture or dislocation from twisting of an extremity or whiplash from shaking the child Present in various stages of healing Laceration and abrasions Arms, legs, torso, face, external genitalia Fearful, withdrawn, passive, especially in presence of abuser Wary of physical contact with adults Apparent fear of parents or going home Lying very still while surveying environment Inappropriate reaction to injury, e.g. failure to cry from pain Lack of reaction to frightening events Apprehensive when hearing other children cry Indiscriminate friendliness and displays of affection Superficial relationships Acting out behavior, e.g. aggressiveness Withdrawal behavior

5 Abuse and Neglect, Guidelines for Suspicion of RI-002 Page 5 of 11 Unusual symptoms, e.g. abnormal swelling, pain and/or vomiting from punching Descriptive marks, e.g. human bites, pulling out hair Present in various stages of healing Chemical Unexplained repeated poisoning, especially drug overdose Unexplained sudden illness, e.g. hypoglycemia from insulin Sexual Abuse Bruises, bleeding, lacerations, irritation of external genitalia, anus, mouth or throat Torn, stained or bloody underclothing Pain on urination, pain, swelling, itching of genital area Penile discharge Sexually transmitted disease, nonspecific vaginitis, venereal warts Difficulty in walking, sitting Unusual odor in the genital area Recurrent urinary tract infection Presence of sperm Pregnancy in young adolescent Fearful, withdrawn, passive, especially in presence of abuser Sudden emergence of sexually related problems, including excessive or public masturbation, age inappropriate sexual play, promiscuity, overtly seductive behavior Withdrawn, excessive daydreaming Preoccupied with fantasies Poor relationships with peers Sudden changes, e.g. anxiety, loss or gain of weight, clinging behavior Incestuous relationship, excessive anger at mother for not protecting daughter Regressive behavior, e.g. thumb sucking, bed wetting Sudden onset of phobias, fears, particularly fears of the dark, men, strangers, particular settings or situations, e.g. undue fear of leaving the house or staying at the day care center or sitter s house Running away from home Substance abuse Profound and rapid personality changes, especially extreme depression, hostility and aggression Rapidly declining school performance

6 Abuse and Neglect, Guidelines for Suspicion of RI-002 Page 6 of 11 ELDER or DEPENDENT ADULT ABUSE Type of Abuse Physical Criteria Behavioral Criteria Physical Injuries which are unexplained or explanation is inconsistent with medical findings Fractures Fearful, withdrawn, passive, especially in presence of abuser Welts Anxiety Lacerations Depression Punctures Reluctant to answer questions Burns, especially if patterns are May suddenly refuse descriptive of object used, e.g. treatment or leave facility cigarette, iron Overly anxious to explain Bruises, especially if patterns are away injuries occurred descriptive of object used, e.g. belt Self-deprecating, e.g. I m buckle, hand stupid or I m clumsy Injuries in various stages of healing Frequent injuries from lack of supervision Sexual Bruises, bleeding, lacerations, irritation of external genitalia, anus, mouth or throat Torn, stained, bloody underclothing Pain on urination, pain, swelling, itching of genital area Sexually transmitted disease, nonspecific vaginitis, venereal warts Difficulty in walking, sitting Recurrent urinary tract infection Presence of sperm Psychological/Emotional Abuse Financial/Material Abuse Confusion Insomnia Unusual weight gain or loss Inaccurate, confused or no knowledge of finances Unexplained or sudden inability to pay bills, purchase food or personal items Neglect Dehydration Malnutrition Hypothermia Hyperthermia Excessive dirt, odor Shame, fear, anxiety Reluctance to talk to anyone, ambivalent or negative response Withdrawal Fear of caregiver Excessive fears Sleep deprivation or need for excessive sleep Change in appetite Loss of interest in self, activities or environment Ambivalence Resignation Withdrawn Agitation Self-deprecating, e.g. I m clumsy or I m stupid Inadequate or inappropriate clothing Lack of eyeglasses, hearing aids, dentures, or prostheses Signs of excessive drugging Lack of medication Decreased alertness, responsiveness, or orientation Multiple missed appointments Inadequate or inappropriate clothing Lack of eyeglasses, hearing aids, dentures, or prostheses Signs of excessive drugging

7 Abuse and Neglect, Guidelines for Suspicion of RI-002 Page 7 of 11 Decubitus ulcer Unexpected, unexplained deterioration of health Lack of medication Decreased alertness, responsiveness, or orientation Multiple missed appointments DOMESTIC ABUSE Type of Abuse Physical Criteria Behavioral Criteria Physical Abuse Injuries which are unexplained or explanation is inconsistent with medical findings: Fractures Welts Lacerations Punctures Burns, especially if patterns are descriptive of object used, e.g. cigarette, iron Bruises, especially if patterns are descriptive of object used, e.g. belt buckle, hand Injuries in various stages of healing History of seeking treatment from different settings and/or from multiple providers Sexual Bruises, bleeding, lacerations, irritation of external genitalia, anus, mouth or throat Torn, stained, bloody underclothing Pain on urination, pain, swelling, itching of genital area Penile discharge Sexually transmitted disease, nonspecific vaginitis, venereal warts Difficulty in walking, sitting Unusual odor in the genital area Recurrent urinary tract infection Presence of sperm Fearful, withdrawn, passive, especially in presence of abuser Anxiety Depression Reluctant to answer questions Suddenly decides to refuse treatment or leave facility Overly anxious to explain away any injuries Self-deprecating, e.g. I m stupid, or I m clumsy Shame, fear, anxiety Reluctance to talk to anyone, ambivalent or negative response Withdrawal Fearful of caregiver Fearful of partner

8 Abuse and Neglect, Guidelines for Suspicion of RI-002 Page 8 of 11 Appendix B MR-1552 Notice of Legal Rights/Remedies for Assault Saint Vincent Healthcare P.O. Box 35200, Billings, Montana NOTICE OF LEGAL RIGHTS AND REMEDIES WHEN PARTNER OR FAMILY MEMBER ASSAULT IS SUSPECTED Whenever a patient seeks health care and the healthcare provider suspects that partner or family member assault has occurred, the healthcare provider, outside the presence of the suspected offender, may advise the suspected victim of the availability of a shelter or other services in the community and give the victim immediate notice of the following available legal rights and remedies. The city or county attorney's office can file criminal charges against the offender if the offender committed the offense of partner or family member assault. In addition to the criminal charges filed by the state of Montana, you are entitled to the civil remedies listed below. (You may want to seek legal counsel by contacting an attorney to assist with this process) 1. You may go to court and file a petition requesting any of the following orders of relief: an order of protection that prohibits the offender from threatening to hurt you or hurting you; an order of protection that directs the offender to leave your home and prohibits the offender from having any contact with you; an order of protection that prevents the offender from transferring any property except in the usual course of business; an order of protection that prohibits the offender from being within 1500 feet or other appropriate distance of you, any named family member, and your worksite or other specified place; an order of protection that gives you possession of necessary personal property; an order of protection that prohibits the offender from possessing or using the firearm used in the assault 2. If you file a petition in District Court, the District Court may order all of the above and may award custody of your minor children to you or the other parent. The District Court may order visitation of your children between the parents. The District Court may order the offender to pay support payments to you if the offender has a legal obligation to pay you support payments. 3. The forms that you need to obtain an order of protection are at the Yellowstone County Justice and District Courts. You may call the Justice or District Court Clerks at the Yellowstone County Court House for additional information about an order of protection. 4. You may file a petition in District Court at the Yellowstone County Court House. 5. You may be eligible for restitution payments from the offender (the offender would repay you for costs that you have had to pay as a result of the assault) or for crime victims compensation payments (a fund administered by the state of Montana for innocent victims of crime). You may call personnel at the County Attorney's office or the Department of Justice Crime Victims Unit, 303 No. Roberts, 4th Floor, Helena, MT 59601, (406) for additional Information about restitution or crime victim s compensation. The agencies listed In the Family Violence Resource Handbook for Yellowstone and Surrounding Counties published by the Yellowstone County Sheriff's Office and the Billings Area Family Violence Task Force may be able to give you additional information or emergency help." This information has been reviewed with the patient. Legal Rights/Remedies for Assault info sheet and booklet TAKEN by patient. Legal Rights/Remedies for Assault info sheet and booklet NOT TAKEN by patient. Patient's Signature Date Time Employee's Signature Date Time Rev. (6/06) Original -Patient Copy-Medical Record NOTICE OF LEGAL RIGHTS/REMEDIES FOR ASSAULT MR-1552

9 Abuse and Neglect, Guidelines for Suspicion of RI-002 Page 9 of 11 Appendix C YOU CAN Prevent Elder Abuse Department of Public Health & Human Services What is Elder Abuse? Montana law defines abuse as infliction physical or mental injury or the deprivation of food, shelter, clothing or services necessary to maintain the physical or mental health of an older person or a person with a developmental disability without lawful authority. The federal definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Report the following in accordance with 42 CFR (b) & (c): Injury of unknown source Misappropriation of resident property (theft) Neglect Mistreatment Resident to resident abuse Staff to resident abuse Volunteer to resident abuse Other employee to resident abuse Resident to staff abuse, resident falls and resident elopements are NOT required to be reported to the Certification Bureau. Provide the following information when calling in abuse and/or neglect: 1. Your name 2. The facility s name 3. The date of your call 4. The date of the incident 5. The time of the incident 6. The name of the resident(s) 7. The name of the staff person (if applicable) 8. The name of the victim 9. The name of the aggressor/perpetrator 10. The extension of any injuries; and 11. The prevention plan to stop further abuse during investigation Investigation results are to be sent to the Certification Bureau within 5 working days of the receipt of the reported abuse. Please include in addition to the above 11 items, the following: 12. The outcome of your investigation 13. Your plan to prevent the same sort of incident or abuse/neglect in the future 14. The action taken against the aggressor (Staff or resident) 15. The name and date of the person who conducted and completed the investigation CMS believes immediately means as soon as possible but ought not exceed 24 hours after discovery of the incident Based on S&C-05-09, December 16, 2004; as specified in 42 CFR (a) (2) and (4), the following alleged of violations and the results of all investigations must be reported to the administrator of the facility, other officials in accordance with state law, and the state survey and certification agency. The alleged violations are defined as follows: Neglect failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Abuse The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish Injuries of unknown source An injury should be classified as an injury or unknown source when both the following conditions are met: The source of the injury was not observed by any person or the source of the injury 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 or the number of injuries observed at one particular point in time or the incidence of injuries over time Misappropriation of resident property The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a residents belongings or money with the resident s consent (42 CFR ) Contact Numbers & Web sites for reporting and investigating and preventing abuse in Montana Nursing Homes State LTC Ombudsman Local Law Enforcement Certification Bureau Montana ID Bureau Certification Abuse Coordinator Web Con:

10 Abuse and Neglect, Guidelines for Suspicion of RI-002 Page 10 of 11 Certification Abuse Reporting U.S. Department of Justice C. N. A Registry Medicaid Fraud Inspector General Medicare/Medicaid Fraud Mountain Pacific Quality Health Foundation Complaint Coordinator or ext References: Montana Code Annotated 2009 Appendix C: YOU CAN Prevent Elder Abuse, Mandatory Reporting for Nursing Facilities, Department of Public Health and Human Services Quality Assurance Division Certification Bureau CMS (c) (3) CAMH 2011 PC ; RI