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Hospital Accreditation

Protecting Patients from Abuse & Neglect
Posted by
on 5/23/2017 10:00:00 AM
It was probably one of the worst nights of my nursing career. I was a house supervisor at a small community hospital. Around 2:30 in the morning, I was called to the Emergency Department. A small child around 5 years of age had been severely beaten by her so-called “mother”. I have another name for this type of sub-human but I can’t put it into print. The child’s face so swollen and bruised you could barely see her eyes. Broken ribs, a skull fracture, and cigarette burns on her back rounded out the bleak story of this child’s existence. The images haunt me to this day.
If you’ve worked in healthcare for any length of time, this story probably sounds depressingly familiar. I tell it – not for shock value (although it should shock anyone with an ounce of compassion) – but to highlight the importance of implementing processes in our hospitals to identify and protect patients from abuse and neglect. Unfortunately, there is not much we can do to prevent such tragedies outside the walls of our hospitals, but we certainly can protect patients in our care.
CMS and accrediting organizations have – rightly so – strong expectations around protecting patients from abuse and neglect by staff. The interpretive guidance under Appendix A of the State Operations Manual for §482.13(c)(3) forms the basis for this discussion.
Per CMS, your hospital must ensure that patients are free from all forms of abuse, neglect or harassment. There must be mechanisms/methods in place that ensure patients are free of all forms of abuse, neglect or harassment.
CMS defines abuse as “the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.”
The following components are suggested by CMS as necessary for effective abuse and neglect protection:
Prevent
Research has shown that one of the underlying causes of patient neglect in hospitals is due to lack of staffing – especially on nights, weekends, and holiday. Staffing patterns should be regularly analyzed to assure that there are adequate numbers and qualifications to meet patient care needs.
Screen
Persons with a record of abuse or neglect should not be hired or retained as employees. While not prescriptively mandated, potential employees should undergo a background check and be cleared prior to employment. This should be required of contract staff as well. I once surveyed a children’s hospital that screened all visitors by requiring a fingerprint that automatically checked sex offender registries – in real time. What a great idea!
Train
Your hospital, during its orientation program and through an ongoing training program (recommend annually), should provide all employees with information regarding abuse and neglect and related reporting requirements, including prevention, intervention and detection. This training should be documented.
Protect
If there is an allegation of abuse or neglect against a staff member, your hospital must protect patients while an investigation occurs. This means that the staff person must be removed from all patient contact until the investigation is completed. Failure to do so would be considered an immediate threat to a patient’s health and safety.
Investigate
The hospital must ensure that there is an objective investigation of all allegations of abuse, neglect or mistreatment, and that it occurs in a timely manner. There should be thorough documentation of all aspects of the investigation. I would recommend getting risk management and legal counsel involved early on.
Report
Your hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law.
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About the Author

Richard Curtis RN, MS, HACP
RN, MS, HACP

Richard (Rick) Curtis is the Chief Executive Officer for CIHQ. Rick is nationally recognized as an expert on the Medicare Conditions of Participation and the CMS Certification & Survey Process. As CEO, he successfully guided CIHQ in becoming the nation's 4th CMS approved deeming authority for acute care hospitals.
Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.
Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.
Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.
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