Administrative Manual

Section:

Policy Number: 3.03

ADULT ABUSE, NEGLECT, EXPLOITATION OR ENDANGERMENT

Objective:To provide guidelines for Covenant HealthCare System employees at the time that they identify or suspect adult abuse, neglect, exploitation or endangerment, in accordance with the mission, vision, and values of the organization, and the standards of professional, accrediting, and regulatory agencies.

Scope: All staff of Covenant HealthCare System.

Policy:Adult Protective Services, (APS) as required by Act No. 519, Public Act of 1982, requires certain professionals and other employees in the fields of health care, mental health, social work, law enforcement, education and other human services to report suspected cases of adult abuse, neglect, exploitation or endangerment to the Department of Social Services.  Adult abuse/neglect includes non-accidental physical or mental injury, exploitation, neglect or endangerment of a vulnerable adult.

When there is a suspicion of adult abuse or neglect, the Health Care Professional will immediately file a report to Adult Protective Services (APS), a part of the Michigan Department of Human Services (DHS).

Social Worker(s) will be available to assist with reporting abuse or neglect and will follow up with assigned APS worker. 

• Mandated APS reporting is initiated for the following situations:

• Types of Abuse
  • Abuse:  Any harm or threatened harm to an adult’s health or welfare caused by another person.  This includes non-accidental physical injury, mental injury, sexual abuse, or maltreatment.
  • Neglect:  Any harm to an adult’s health or welfare caused by the conduct of a person responsible for the adult care.  This includes failure to provide adequate food, clothing, shelter or medical care.  Self-neglect is also included.
  • Exploitation:  Any action which involves the misuse of an adult funds, property, or personal dignity by another person.
  • Endangerment:  A life-threatening situation caused by the inability of the person whose life is threatened to respond.
  • Vulnerable:  A condition in which an adult is unable to protect him/herself from harm, described above, because of a physical or mental impairment or because of advanced age (over 65).

Procedure:

• Suspected Adult abuse, neglect and/or exploitation can be reported to Adult Protective Services, (a division of the Department of Human Services) twenty-four hours a day, seven days a week.  The contact numbers for Adult Protective Services are as follows:
  • Centralized Intake Phone:
    • (855) 444-3911
  • Fax to Adult Protective Services:
    • (616) 977-1158
• The report shall be made as soon as there is suspicion to believe an adult has been abused, neglected or exploited.
  • Information requested:
    • Name, age, and address of the adult in danger.
    • Description of neglect exploitation and endangerment.
    • Names and addresses of next of kin or guardian, if any.
    • Names of others in the dwelling and relationship to the adult, if any.
    • Description of the present situation.
    • Any other information available, which establishes the cause of the situation and the manner in which it occurred.
    • Be sure to detail the factors that make the adult vulnerable, e.g. disability, wheelchair bound, etc.

• Physician or RN notifies the Social Worker via consult in EPIC and by phone
• RN notifies the Unit Clinical Coordinator/Charge Nurse of the reported abuse or neglect, who contacts the Nurse Manager or Administrative Coordinator during off hours. 
• If the APS worker requests the medical record, the Healthcare Professional will refer the APS worker to Social Work. In absence of Social Work, refer to the HIM Department, Release of Information Desk: 989-583-6097. 
  • In an emergency situation, e.g., the APS worker states they have an urgent need for documents from the chart of the victim (history & physical, imaging, lab results, etc.), the Healthcare Professional may give out documentation that directly relates to the reason for suspected abuse/neglect.  The Healthcare Professional must document the disclosure and leave a detailed list for the Social Worker. Social Work is responsible to complete HIM disclosure records on all material given out to APS directly from the Units. Due to regulations regarding such disclosures, it is preferable that APS obtain any chart documentation from either the Social Worker or the HIM Release of Information Desk, as most situations can wait for this to occur.  Refer to Administrative Policies: 13.52.
• The Social Worker will provide follow-up as needed according to Clinical Resource Management (CRM) policies, and will ensure the disclosure of all the protected health information given to CPS is entered into EPIC ROI (release of information).
• If the social worker cannot see the patient prior to discharge (such as on a weekend) the staff identifying the abuse/neglect will provide the patient/family with a list of community resources for victims.  (See attached “Resources for Survivors of Abuse/Neglect and Violence”.)
• If the alleged abuse or neglect has occurred in a licensed or certified facility or program and the Social Worker cannot see the patient prior to discharge, the staff identifying the abuse/neglect will provide the patient or family with a list of Advocacy Programs.  (See attached “Advocacy for Victims of Abuse or Mistreatment”.)
• Report to the police department whenever a person suffers from an injury caused by a knife, gun, pistol or other deadly weapon or other means of violence.
  • The law provides immunity for civil liability for those reporting suspected cases and keeps the name of the complainant confidential.
  • The law also contains a penalty for failure to report cases of injuries as a result of violence.

Documentation:

• Document all injuries precisely (including shape, size, location, and appearance) in the patient’s medical record.
• All relevant verbal statements made by the patient and care givers/family members should be documented verbatim using direct quotations.
• Document to Centralized Intake, and all interactions with Adult Protective Services on the EMR:
  • Name, county, and phone number of the Protective Service Worker contacted
  • APS worker’s intentions regarding follow up
  • APS instructions given to staff on how to proceed with the case.
• Ensure original copy of completed 3200 form is in the front of the patient’s paper medical record.

Related Policies and Procedures: 

• Administrative Policy 3.04:  Abuse, Neglect, Exploitation or Endangerment – Child
• Administrative Policy 13.52:  Disclosing Protected Health Information about Victims of Abuse, Neglect, or Domestic Violence
• CRM Policy 1.010:  Policy for Suspected Adult Abuse or Neglect
• CRM Policy 1.020:  Policy for Suspected Child Abuse and/or Neglect

Approval:

_______________________________________________March, 2016

Beth Charlton – Vice President Patient Services/CNO               Date

_______________________________________________March, 2016

Daniel George – Executive Vice President/OperationsDate

_______________________________________________March, 2016

James Hines, MD – Chief of StaffDate

Resources for Survivors of Abuse/Neglect and Violence

Advocacy for Victims of Abuse or Mistreatment

If you are abused, you have the right to report and expect an investigation of abuse or neglect committed against you or someone you know.  Similarly, if you feel you have been abused, neglected or mistreated while in a licensed or certified facility or program you have rights to be protected and have your complaint investigated.  This information is being provided to you to help know where you can go to file a complaint or get help to investigate abuse or mistreatment.

IF YOU ARE CONCERNED ABOUT……THEN CALL THE NUMBER BELOW

• CHILD OR ADULT ABUSE BY FAMILY OR CAREGIVER
  • Child or Adult Protective Services
    • Call: 1-855-444-3911

• PROBLEM WITH COMMUNITY MENTAL HEALTH SERVICES
  • Office of Recipient Rights:
    • In Saginaw, call: 797-3452
    • State Office of RR: 1-800-854-9090

• MISTREATMENT IN ADULT FOSTER CARE, CHILD FOSTER CARE, ASSISTED LIVING
  • Bureau of Family Services Complaint Hot Line
    • Statewide (toll-free): 1-866-856-0126

• MISTREATMENT IN LICENSED FACILITY INCLUDING EXTENDED CARE FACILITY, HOSPITAL, HOSPICE PROGRAM, DIALYSIS PROGRAM, FREE-STANDING SURGICAL CENTER, COUNTY MEDICAL CARE FACILITY OR PSYCHIATRIC HOSPITAL
  • Consumer and Industry Services Complaint Hot Line
    • Statewide (toll-free): 1-800-882-6006

• MISTREATMENT OR COMPLAINT REGARDING NURSING HOME (EXT. CARE FACILITY)
  • Michigan Ombudsman’s Office (also known as “Citizens for Better Care”)
    • In Saginaw area: 746-9216
    • Statewide (toll-free): 1-800-292-7852

• ELDER ABUSE, EXPLOITATION AND MEDICAID FRAUD
  • Michigan Department of Attorney General
    • Statewide (toll-free): 1-800-242-2873

• ABUSE/ MISTREATMENT OF PERSON WITH DISABILITIES
  • Michigan Protection and Advocacy Services
    • Statewide (toll-free):1-800-288-5923

HOW TO FILE A COMPLAINT:

Contact the appropriate organization and be specific as possible about the time, place, names, witnesses and actions of the abuser.  You should file a complaint in writing whenever possible and keep a copy for your files. If you’re not sure who to call, most Investigative Programs will refer you to the appropriate program if they feel you need a different organization than their service. If you have questions or need help, ask your social worker or call an advocacy program such as “Michigan Protection and Advocacy Service” (above).