OF ABUSE/NEGLECT Date Written: 05/94 Date Reviewed/Revised: 11/06 Page No. 1 of 14

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1 University of California Irvine HealthSystem Policy and Procedure Manual MANDATORY REPORTING PATIENT CARE RELATED OF ABUSE/NEGLECT Date Written: 05/94 Date Reviewed/Revised: 11/06 Page No. 1 of 14 I. PURPOSE A. To define the legal requirements for reporting of all child abuse and neglect, dependent adult and elder abuse, physical assault, domestic violence, and spousal/partner abuse to ensure that said policy and procedure is consistent with: 1. California State Law Penal Code, Section , and California Health and Safety Code, Section Welfare and Institution Code, Section Civil Code Title 22 standards. 6. AB 3988, Chapter 769. II. POLICY A. Under the current law, all UCI Medical Center health care providers of all disciplines are mandated to report cases of suspected abuse/neglect which they have knowledge of, or observe in their professional capacity. This includes reported history of abuse and/or neglect. B. If the report is made in good faith, no mandated reporter shall be civilly or criminally liable for reporting a suspected instance of abuse or neglect. If it is found that a report has been made with malice, the reporter can be criminally liable. C. A mandated reporter who fails to make a required report is guilty of a misdemeanor, punishable up to 6 months in jail and/or up to a $1, fine. He/she may also be found civilly liable for failure to report. D. A telephone report is required, as soon as practically possible, by the person who obtained the information or witnessed the event within prescribed time frames (see specific procedures & abuse reporting packets). 1. A written report, prepared by the same person, needs to be completed within the prescribed time frames (see specific procedures & abuse reporting packet). 2. Two or more persons may agree to report as a team and select a member to make the telephone and written report. E. Consultation with a social worker is available through the Clinical Social Work Department at After hours pager may be used to contact the Chief of Clinical Social Work for telephone consultation.

2 Page 2 of During the weekend, an on-call social worker is available for telephone consultation using pager F. Pictures are obtained for the medical record through the Emergency Department Physician, house supervisor or UCI Security. G. Interdisciplinary Notes in the patient's medical record will be used to document statements relating to: 1. The home situation, specifics surrounding the resultant injury or situation, abuse or neglect reported by the patient/parent or care provider. 2. Interaction between the patient and care provider. 3. General behavioral observations of patient/parent or care providers. 4. Routine patient care observations and provisions of care. 5. Visitation, including visitor s name, frequency and length of visit. I. The patient will be placed in a room as close to the nursing station as possible. 1. To provide for frequent nursing observations. 2. To avoid proximity to exit doors. J. The patient will be accompanied by staff personnel whenever off the unit. K. Supervised visitation can be permitted for parents and/or significant others, unless otherwise documented in patient record. L. Escalation in the form of threats against the patient and/or staff, a question of the victim being removed from the Medical Center without proper authorization, questionable behavior by visitors, or extraordinary incidents occurring while the patient is hospitalized require: 1. Increase in patient supervision 2. Notification of the UCI Security Department x Notification of the Clinical Social Work Department, x Documentation of the problem in the patient's medical record and completion of an event report 5. Increased security as determined by the UCI Security Department in consultation with Medical, Nursing and Clinical Social Work staff. M. A suspected victim of abuse may be placed in protective custody (hospital hold) at the discretion of the police department in the city where the abuse occurred or by Orange County Department of Social Services. N. In a case of suspected abuse, where the possibility exists that person(s) will attempt to remove the suspected victim from this vicinity, the UCI Security will cooperate with Nursing and Clinical Social Work to place the child in protective custody until the Child Abuse Registry (CAR) can investigate. O. Admissions will be notified by Nursing/Clinical Social Work/Case Management staff when a patient is placed in protective custody (hospital hold). P. If Orange County Department of Social Services or local law enforcement decides

3 Page 3 of 14 against placing a hospital hold and the physician deems it urgently necessary, the physician may then pursue further action with CAR Supervisor and/or supervisor for the local law enforcement agency. III. PROCEDURE RESPONSIBLE PERSON(S)/DEPT. PROCEDURE IDENTIFICATION OF CHILD ABUSE/NEGLECT MD, RN, CM, CSW MD 1. The possibility of a child being physically or sexually abused and/or neglected should be considered when any of the following conditions are present. The following is a partial list of the indicators of suspicion, either current or reported history: 1. Lack of a plausible explanation for the injury, several different explanations or an explanation that is inconsistent with child's age and injury. 2. Multiple or recurrent injuries or bruising in patterns, or on areas of the body which are suspicious or uncharacteristic. 3. Delay in seeking medical treatment. 4. Non-organic failure to thrive (after medical causes have been ruled out). 5. General neglect (lack of supervision, medical care, personal care, food). 6. A child is dead on arrival or expires. 7. Appearance of severe emotional trauma. 8. Any suggestion of sexual activities between child and another individual. 9. Positive toxicology screen for mother and newborn infant. 10. Burns. 11. Subdural hematomas. 12. Fractures, especially long-bone fractures. A. PROCEDURE FOR REPORTING CHILD ABUSE/NEGLECT 1. Document in the medical record the nature of the injury as described by the child and/or the parent/care provider s explanation. 2. Skeletal survey should be considered when the

4 Page 4 of 14 child is under three years of age and fractures are suspected. 3. An ophthalmology exam should be considered if shaken child syndrome is suspected. Reporting Party 4. Call CAR immediately at (714) to report the suspicious incident. The intake worker for CAR will give instructions regarding the acceptance of the referral and the anticipated response time. Document report and response time in patient s medical record 5. Complete Child Abuse Reporting Form SS8572 (available on Nursing Units and in Clinical Social Work Department) and place appropriate copy in the patient's medical record. HUSC MD, RN, CSW, CM MD, RN, CSW RN, CM 6. Forward completed Child Abuse Reporting Form to Clinical Social Work, Route 176, for review and routing to CAR within 36 hours of report. 7. Document visitation guidelines and/or supervision, in the patient's medical record. This information must also include any restrictions, regarding overnight visitation of parents or other significant adults. 8. Carefully review written authorization from Orange County Social Services or Juvenile Court before release of a child currently in protective custody (hospital hold) (F ). 9. Disposition of the child will be made by the Orange County Social Services Representative. The child will be discharged to the Orange County Social Services Representative: parent, relative, foster parent who has been granted custody of the child by the Juvenile Court or Orange County Social Services. They will present with proper identification, CA drivers license or CA Identification card. In the event placement has not been determined prior to patient becoming medically stable, contact Orangewood Children s Home.

5 Page 5 of 14 Regarding discharge to Orangewood Children s Home: a. Complete Medical Clearance Form in preparation for discharge. This is a worksheet only. b. Contact the Orangewood Children's Home (OCH) intake screeners ( ) with the information on the OCH Medical Clearance Form when patient is medically ready for discharge to Orangewood Children's Home. c. Complete OCH Discharge Information and Placement Sheet. 10. Disposition of the child will be determined by Orange County Social Services with subsequent notification regarding acceptance and anticipated pick-up time. HUSC 11. If discharged to Orangewood, provide OCH Discharge Information and Placement Sheet, copy of UCIMC Discharge Summary, and a copy of child's medical record at the time of discharge to Orangewood Children's Home. B. PROCEDURE FOR REPORTING CHILD SEXUAL ABUSE MD MD, RN, CSW, CM 1. Examine peripherally for indicators of suspected sexual abuse if penetration or collectable evidence is suspected within the past 24 hours. 2. Refer suspected sexual abuse directly to the Child Abuse Registry at (714) They will contact Child Abuse Services Team (CAST) at (714) if indicated. 3. If patient is medically stable, contact CAR or local police department to get authorization to transport patient to CAST for examination. Reporting Party, MD 4. Complete Medical Report-Suspected Child Sexual Abuse Form (if >72 hours, Form OCJP925; if < 72 hours, Form OCJ930) and forward to CAR along with completed Suspected Child Abuse Report. One copy of

6 Page 6 of 14 each is to be placed in patient s medical record. MD MD, RN, CSW, CM HUSC MD, RN, CSW, CM MD, RN, CSW RN, CM 5. You may contact CAST to consult on medical concerns. 6. Forward reports to CAR. One copy of each is to be placed in the patient s medical record. 7. Forward completed Child Abuse Reporting Form to Clinical Social Work, Rte. #176 for review and routing to CAR within 36 hours of report. 8. Document visitation guidelines and/or supervision in the patient s medical record. This information must also include any restrictions regarding overnight visitations of parents or other significant adults. 9. Carefully review written authorization from Orange County Social Services or Juvenile Court before release of a child currently in protective custody (hospital hold) (F ). 10. Disposition of the child will be made by the Orange County Social Services Representative. The child will be discharged to the Orange County Social Services Representative: parent, relative, foster parent who has been granted custody of the child by the Juvenile Court or Orange County Social Services. They will present with proper identification, CA drivers license or CA Identification card. In the event placement has not been determined prior to patient becoming medically stable, contact Orangewood Children s Home. Regarding discharge to Orangewood Children s Home: a. Complete Medical Clearance Form in preparation for discharge. This is a worksheet only.

7 Page 7 of 14 b. Contact the Orangewood Children's Home (OCH) intake screeners ( ) with the information on the OCH Medical Clearance Form when patient is medically ready for discharge to Orangewood Children's Home. RN, CM, CSW HUSC MD, RN c. Complete OCH Discharge Information and Placement Sheet. 10. Disposition of the child will be determined by Orange County Social Services with subsequent notification regarding acceptance and anticipated pick-up time. 11. If discharged to Orangewood, provide OCH Discharge Information and Placement Sheet, copy of UCIMC Discharge Summary, and a copy of child's medical record at the time of discharge to Orangewood Children's Home. 12. Discharge the child to Orange County Social Services Representative with California Drivers License or California Identification or a parent or relative granted custody of the child by the Juvenile Court or Orange County Social Services, who presents with authorization, in addition to proper identification. C. PROCEDURE FOR REPORTING MATERNAL SUBSTANCE ABUSE MD MD, RN, CSW 1. If maternal substance abuse is suspected, write an order to confine a newborn infant to the nursery for observation and the collection of evidence, e.g. urine toxicology screen. Withdrawal symptoms must be documented when maternal/child substance abuse has been documented. 2. Obtain the toxicology results from TDS for mother and newborn prior to filing the Suspected Child Abuse Report Form with CAR (Child Abuse Registry). 3. Obtain supplemental information regarding maternal substance abuse which is required by Orange County Social Services on the Maternal

8 Page 8 of 14 Substance Abuse Assessment Protocol (F ) which must accompany the Suspected Child Abuse Reporting Form. One copy of each is to be placed in the patient s medical record. 4. To comply with Orange County Health Agency mandate regarding aftercare of a substance exposed infant, a copy of the Maternal Substance Assessment Protocol must also accompany the Interagency Referral (F ). HUSC MD, RN, CSW, CM MD, RN, CSW RN, CM 5. Forward completed Child Abuse Reporting Form to Clinical Social Work, Rte. #176 for review and routing to CAR within 36 hours of report. 6. Document visitation guidelines and/or supervision in the patient s medical record. This information must also include any restrictions regarding overnight visitations of parents or other significant adults. 7. Carefully review written authorization from Orange County Social Services or Juvenile Court before release of a child currently in protective custody (hospital hold) (F ). 8. Disposition of the child will be made by the Orange County Social Services Representative. The child will be discharged to the Orange County Social Services Representative: parent, relative, foster parent who has been granted custody of the child by the Juvenile Court or Orange County Social Services. They will present with proper identification, CA drivers license or CA Identification card. In the event placement has not been determined prior to patient becoming medically stable, contact Orangewood Children s Home. Regarding discharge to Orangewood Children s Home: a. Complete Medical Clearance Form in preparation for discharge. This is a

9 Page 9 of 14 worksheet only. b. Contact the Orangewood Children's Home (OCH) intake screeners ( ) with the information on the OCH Medical Clearance Form when patient is medically ready for discharge to Orangewood Children's Home. c. Complete OCH Discharge Information and Placement Sheet. RN, CM, CSW HUSC 9. Disposition of the child will be determined by OCH with subsequent notification regarding acceptance and anticipated pick-up time. 10. Provide OCH Discharge Information and Placement Sheet, copy of UCIMC Discharge Summary and a copy of child s medical record at the time of discharge to Orangewood Children s Home. IDENTIFICATION OF DEPENDENT ADULT/ELDER ABUSE/NEGLECT A. The possibility of a dependent adult or an older adult being physically abused, neglected or the victim of fiduciary abuse should be considered when any of the following conditions are present. The following is a partial list of the indicators or suspicion. 1. Unexplained bruises, welts, lacerations, cuts or punctures. 2. Bone fractures, sprains or dislocations. 3. Burns, scalding, freezing. 4. Sexual assault, sexual exploitation (refer to Form OCJP923) 5. Direct beatings, confinement (tied, locked up). 6. Internal injuries. 7. Overmedication. 8. Verbal and emotional abuse. 9. General neglect (lack of supervision, medical care, personal care, food). 10. Misuse of funds or property, extortion, duress, fraud or theft. 11. Self-neglect/inability to perform self-care tasks and/or obtain appropriate services.

10 Page 10 of 14 B. There are other categories of elder/dependent adult abuse in addition to physical abuse. Under California State Law, reporting of these other types of abuse is not mandatory, but it is highly recommended. Other types of abuse include: 1. Psychological abuse, this includes: a. threats b. insults c. harassment d. refusal to allow travel e. refusal of visits by friends or family f. refusal of church attendance 2. Fiduciary abuse (financial exploitation) 3. Neglect by caretakers - this can be active such as purposeful withholding (or inappropriate administration) or medications or necessary medical treatment, or passive neglect where the caretaker/abuser is not aware of the person's needs. This is the most common type of abuse. PROCEDURE FOR REPORTING ELDER/DEPENDENT ABUSE/NEGLECT MD, RN, CSW, CM MD, RN, CSW MD, RN MD, RN, CSW, CM 1. Document in the patient's medical record the nature of the injury and the explanation provided by the care provider (Form OCJP602) 2. Interview the older adult alone in order to document his/her explanation of the suspected abuse. 3. Conduct a thorough examination of the patient. Look for any evidence of old as well as current trauma, lesions, ecchymoses and old scars. 4. Assess the risk for older adult to return to their home/ institution where the abuse occurred. 5. Determine the location where the suspected abuse allegedly occurred and contact the appropriate agency as follows: a. Abuse occurring in long-term care facility in Orange County, contact the Long Term Care Ombudsman b. Abuse occurring in long-term care facility in

11 Page 11 of 14 another California county, call (Crisis Line). c. Abuse occurring in all other locations (i.e. home), contact Adult Protective Services After hours, contact local Police Department to report. Reporting Party Reporting Party Reporting Party 6. Complete the Report of Suspected Dependent Adult/Elder Abuse Form and place appropriate copy in patient's medical record. 7. Place copy of the report in patient's medical record. 8. Document report and response in patient's medical record. PROCEDURE FOR REPORTING DEPENDENT ADULT/ELDER ABUSE SEXUAL ASSAULT MD A. If signs of sexual assault are found, complete the Medical Report, Suspected Sexual Assault (OCJP923). Telephone law enforcement agency in the jurisdiction where the assault occurred to report findings. Follow steps 1-8 above. IDENTIFICATION OF DOMESTIC VIOLENCE- SPOUSAL/PARTNER ABUSE A. The possibility of domestic violence should be considered when any of the following conditions are present. The following is a partial list of the indicators of suspicion, either current or reported history. 1. Injuries inconsistent with the explanation given. 2. Repeated visits for injuries, vague or stress related complaints, or emotional problems. 3. Multiple injuries in various stages of healing. 4. Significant delay in seeking treatment for injuries. 5. Injuries to the face, head, neck, chest, abdomen, or genitals (Central type injuries are more frequent with battering). 6. Injuries during pregnancy (abused women are battered more frequently while pregnant). 7. Suicidal ideation or suicide attempts (Battering is a frequent precipitant of suicide attempts). 8. History of sexual abuse.

12 Page 12 of 14 PROCEDURE FOR REPORTING DOMESTIC VIOLENCE Health Care Provider Specific Department Policy & Procedure All Staff Refer to Form OCJP502 A. Provide separation and privacy when interviewing patient. 1. Place the patient in a private room, if possible. 2. Ask anyone accompanying the patient to stay in the waiting area a. If the abuser is the one who brought the victim to the hospital, the victim will feel threatened to have them present. b. Fear of even greater harm may cause a victim to remain silent. B. Interview the patient in a supportive, non-judgmental manner. 1. Ask direct questions such as, "Where are you hurt?", "How did this happen?", "Are your injuries the result of being hit by someone?", "Has this happened to you before?" 2. Victims who are reluctant to reveal the true source of their injuries may respond to something like "We see many people with injuries similar to yours who have been hit by their partners. Is this what happened to you?" 3. Convey the message that the victim is not alone and that help is available. C. Maintain the victim's safety. 1. Maintain the victim's safety in the Emergency Department by performing the following interventions: a. Carefully screen all visitors. Check on the patient frequently when visitors are present. b. Call Security if needed to ensure the safety and privacy of the patient. c. Maintain strict patient confidentiality. Give no information about the patient to phone inquiries. D. Examination and Treatment 1. Obtain the patient's history noting current, as well as previous areas of injury. Obtain previous medical records if available.

13 Page 13 of 14 Refer to Department Policy & Procedure HUSC Reporting Party 2. Complete appropriate lab and x-ray studies. 3. Treat physical injuries. 4. Record detailed description of all injuries, noting any inconsistencies with the explanation given. E. Collection of Evidence 1. Preserve any physical evidence, such as pieces of glass or wood removed from a wound, torn, or bloodstained clothing. a. One person should gather all evidence. Place evidence in a paper bag or envelope. Seal envelope and label with patient's name, date, time, source of specimen, and name and title of person collecting evidence. b. Keep evidence locked up until relinquished to the law enforcement officer taking the report. Do not leave evidence unattended or in the presence of the victim. Document the name of the officer, badge number and responding agency in the victim's medical record. c. If photographs are taken by hospital staff, obtain "Consent to Photograph". 2. Place copy of Form OCJP502 in patient s medical record. 3. Mail copy of completed form to same law enforcement agency. 4. Document report and response in patient's medical record. Health Practitioner F. The health practitioner is required to make a report by telephone as soon as possible and send a written report within two (2) working days. Two (2) or more persons may agree to report as a team and select a member to make the telephone and written report. Explain to the victim that California Law requires any health practitioner who knows, or reasonably suspects a person has suffered any injury as the result of assaultive or abusive conduct or behavior to make a report to law enforcement whether or not the victim wishes to press charges, the person has expired, regardless of whether or not the injury contributed to the death.

14 Page 14 of 14 If patient is not injured as a result of domestic violence, but the healthcare practitioner highly suspects domestic violence, it is recommended that a report is made to the local law enforcement even though it is not mandated. 1. Notify the law enforcement agency having jurisdiction WHERE THE ABUSE/ASSAULT OCCURRED. 2. Document the time and name of the person contacted, the name and identification number of the responding officer and the case number. 3. Send an original copy of the report to the law enforcement agency and attach a copy of the written report to the medical record Reporting Party 4. Inquire about the safety of children in the home. Notify the Department of Childrens' Services and/or the Child Abuse Registry (CAR) if indicated. Refer to Department Policy & Procedure G. Intervention and Referrals. 1. Assess the victim's immediate needs. 2. Help the victim to identify any personal support systems. 3. Provide information and/or referrals that will offer the patient continued support and assistance such as: 24 hour hot-line shelters for abused women counseling services and support groups legal assistance hot-lines 4. Give the victim preprinted information with referrals for information on domestic violence. 5. Provide a safe place for the victim to make telephone calls. 6. Document referrals given and the victim's stated plan in the medical record. H. If signs of sexual assault are found, complete the Medical Report Suspected Sexual Assault (OCJP923). PROCEDURE FOR REPORTING ADULT SUSPECTED SEXUAL ASSAULT Healthcare Provider A. Follow steps A-E above

15 Page 15 of 14 MD B. Examine peripherally for indications of sexual abuse if penetration or collectible evidence is suspected within the past 24 hours. MD/RN/CM C. Discharge patient to safe house at Anaheim Memorial Hospital for sexual assault evaluation. Author: Approvals: Michelle Thomas Director, Clinical Social Work Policy Review Committee January 09, 2007 Performance Improvement Committee January 10, 2007 Med Exec Committee January 15, 2007 Governing Body January 22, 2007