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Based on record reviews and interviews, the facility Governing Body failed to ensure that patients were treated with dignity, respect, and were protected from physical, verbal and emotional abuse and neglect.

The Governing body failed to ensure the Abuse, Neglect and/or Exploitation policy thoroughly defined the term "Adult" as well as all types of abuse (physical, verbal, emotional, sexual)

This deficient practice placed all patients receiving treatment in the facility at an increased risk of experiencing ongoing verbal, physical and/or emotional abuse and neglect.

Findings included:

Record review of the facility Policies and Procedures entitled: Reporting Suspected Abuse, Neglect and Exploitation of Children, the Elderly, and/or Disabled Persons, revised on 06/28/2023, revealed the document contained the following:

-Policy:
- To prevent, recognize, and report deliberate and willful injury of a child, elderly, disabled person, or a person of domestic abuse and/or physical assault.
- Child: An unmarried person under 18 years of age
- Disabled: a person with a mental, physical, or developmental disability.
- Elderly: 65 years of age or older.
- Family violence: An act by a member of the family or household that is intended to result in physical harm, bodily injury, assault, or sexual assault, but does not include defensive measures to protect oneself.

There was no evidence that the facility Abuse, Neglect, or Exploitation policy covered patients younger than 65 years old, or that the policy provided for the safety of patients by outlining how the facility staff is to handle the removal of the alleged perpetrator in order to ensure patient safety. In addition, the policy failed to cover the definitions of emotional and/ or verbal abuse of patients.

In an interview conducted on 09/19/2023 at 12:30 pm, the Nurse Educator/ Director of Nursing Informatics confirmed the above findings, and stated that the ANE policy failed to encompass all individuals served by the facility.