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Investigating and Documenting Relevant Facts Demonstrating

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Investigating and Documenting Relevant Facts Demonstrating Demonstrating compliance with § 483.12 Investigating and Documenting Relevant Facts Objectives; briefly review the new regulatory requirements at § 483.12; “Freedom from Abuse, Neglect and Exploitation” discuss the importance of assessing common types of tissue injuries and recognize when indicators of abuse or neglect may be present identify components of an effective and consistent investigative process CMS’s focus of the NEW § 483.12 regulation is to; • ensure that residents are not subjected to abuse, neglect, misappropriation of property, and exploitation • establish requirements for the facility response to any allegations that has occurred Emphasizing that the facility must; • develop and implement written policies and procedures that prohibit and prevent abuse, neglect, misappropriation and exploitation • ensure that direct care/direct access workers are trained to recognize when treatment is abusive or when it constitutes neglect or exploitation • ensure an effective and consistent investigative processes Modified definitions • ‘‘abuse’’ includes actions such as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish • ‘‘willful’’ means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm • ‘‘abuse’’ includes the deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being • ‘‘sexual abuse’’ includes non-consensual sexual contact of any type with a resident • ‘‘neglect’’ 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 illness • ‘‘exploitation’’ is the unfair treatment or use of a resident or the taking of a selfish or unfair advantage of a resident for personal gain, through manipulation, intimidation, threats, or coercion • ‘‘misappropriation of resident property’’ is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident’s belongings or money without the resident’s consent Investigations starts with the gathering information What was reported Clinical assessment Medical history Interviews Injuries of unknown source; When assessing an injury of unknown origin…you’re basically looking at the injury as a potential “crime scene”. all physical findings must be placed within the context of history and functional status of the resident IOU’s classified when… the source of the injury was not observed by any person or the sources 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 Comprehensive assessment of a tissue injury includes; labeling the injury (definition) determining type (patterned or significant) indicators of accidental or intentional injury a full consideration of the physiological aging changes and resident’s medical conditions and functional status Potential physical signs of abuse; Bruises, Abrasions, Contusions, Tears, Lacerations, Rashes, Ulcers, and Significant Injuries the presence (or lack there of) any patterns of injury should be included in the assessment of the injury Pattern bruises; Important to consider the pattern of bruising and whether it is consistent with the history of trauma…. otherwise, it may raise the possibility of non-accidental injury “pattern bruises” show the pattern of the striking object – from finder tips, or a shoe etc. “linear bruises” across the buttocks may be caused by being struck with an object – never accidental Significant injuries; unexplained (large and/or medically serious) and/or unexplained injuries to the breast and/or genitalia ….and should always be reported and investigated! Are the presenting physical signs? Expected sequelae of aging, medications, or disease… ….or as in cases of some bruising, result from an accidental event such as fall Accidental Skin injuries; Common in older adults because of normal physiologic changes and skin integrity is more easily disrupted - • bruises, contusions • tears, lacerations • abrasions be cautious/careful to NOT dismiss skin injuries as normal or expected events Bruising Characteristics; • the disruption of blood vessels caused by blunt force trauma • bruising that is common in aging and sun-exposed skin occurs; on the dorsal aspects of hands/arms referred to as senile purpura Senile purpura Purpura; • a hemorrhagic rash with leakage of blood into the tissue • often associated with bleeding or clotting disorders but, can be abuse-related as seen in some instances with ecchymosis and petechia (ecchymosis and petechia are forms of purpura) • most noticeable sign of purpura is the skin color change • usually the rash that appears will be on the back upper legs or buttocks Petechia; ….pin-point, non-raised, perfectly round, purplish-red purpuric spots caused by an intradermal or sub-mucous hemorrhage When blood is not allowed to leave the head/face because of occlusion or compression of the jugular veins….bursting of capillaries in and around the eyes and face results in Petechia Petechia; ….can be caused by abuse-related behaviors such as; strangulation smothering vigorous shaking of the resident's head Petechia; ….can also be caused by non-abuse-related activities that put stress on the neck muscles, such as; severe coughing and/or sneezing severe vomiting strenuous bowel movements Blood tracking; bruising appears at a site distal to the point of impact, i.e. – . Subgalael hematoma • Battle sign seen behind the ear • Raccoon eyes Bilateral periorbital ecchymoses (raccoon eyes) Location of traumatic bruising; Accidental bruising is more likely to occur on an extremity Traumatic bruises (those that were inflicted) are found more frequently on the head, neck, chest, abdomen, ears, genitalia, buttocks and soles Other skin injuries; • an avulsion pertains to the complete tearing away of a structure or part • skin tears (partial avulsions) to the elderly most often occur to the arms and hands for the skin to tear, there must have been blunt and/or shearing force energies Skin does not spontaneously split open Abrasions; Involve scraping damage to the top layer of skin . common injuries incurred from accidental falls; however, not all falls are accidental . certain types of abrasions are consistent with intentional mechanisms of injury Brush-burn type of abrasion Lacerations; Irregular tear-like wounds from blunt trauma Age-related changes ; Can influence the effects of medications Can lead to adverse drug events (ADEs) An ADE is any injury (physical or mental harm, or loss of function) resulting from medication use may mimic abuse or neglect Adverse Drug Events (ADEs) may be caused by - • increased drug levels • changes in body water, fat, and lean muscle mass • disease-drug and drug-drug interactions ADEs; ….have been linked to the following preventable problems in older adults; •Falls and Hip fractures •Immobility •Confusion and Depression •Constipation “Recognize when treatment is abusive and incidents that constitute neglect or exploitation” -vs- “…..what constitutes abuse, neglect and misappropriation of resident property” Examples of physically abusive treatment; • Hitting with objects • Punching or slapping • Kicking • Biting • Scratching or • Grabbing pinching • Squeezing • Pushing • Confinement Physical signs of abusive treatment; • Cigarette burns • Fractures in various • Bruises in various stages of healing stages of healing • Immersion burns Physical signs of sexual abuse; • Bruises and/or bite • Unexplained marks around breasts vaginal/rectal and/or genitalia bleeding • Lacerations/tears/par • Vaginal/Penile tial avulsions to the discharges genitalia • New onset of • Genital swelling, unexplained sexually redness, and pain transmitted diseases Non-physical signs of abuse; • Resistance by the • Withdrawn behavior resident to peri-care • Depression • Fear, agitation, or • Infantile behavior avoidance around staff• Change in demeanor • Suicidal ideation/death wishes • Loss of appetite • Increased • Ambivalence anxiety/anxiousness • Confusion • Disturbed sleep pattern Warning signs of potential neglect… • sudden weight • malnutrition loss • withdrawn • bedsores, or behavior or pressure ulcers unusual changes • injuries from falls in behavior • dehydration • …etc. Components of an effective and consistent investigative process Abuse investigations should ultimately answer the question of whether or not abuse occurred. Adheres to three criteria: timely thorough / fact-based unbiased Why timely? Memories of events can fade; • evidence may be lost and/or destroyed • there may be collusion among staff to cover up the facts of an event • regulations require submission of investigative summary to SA within 5 days of discovery Demonstrating thoroughness / fact-based investigations; For interviews, start with asking non-leading, open-ended questions in a neutral tone of voice begin with general issues and then become more specific as the interview progresses Demonstrating thoroughness / fact-based investigations; • interview all witnesses or persons of interest • use a standardized protocol to conduct and write up the interview, especially when interviewing persons with cognitive impairments • avoid using trick questions and adversarial
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