HospitalInspections.org

Based on policy and procedure review and staff interview, the hospital failed to ensure there was a comprehensive abuse policy that contained all the required components.

Findings:

This deficiency was cited on a Medicare Recertification Survey on October 26 and 27, 2011. The deficiency stated, "The policies did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker and did not contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect by these individuals."

On 10/15/13 a hospital policy titled, "Abuse Reporting", was provided to the surveyors by Staff A. The hospital's abuse policy was reviewed.

The current policy did not contain all the required components for abuse protection such as:
a. when and how often staff would be trained to identify and report abuse;
b. how the hospital would protect the victim(s) during an investigation;
c. measures the hospital would take to prevent abuse from occurring and;
d. how the hospital would screen potential employees.

The above findings were reviewed with Staff A on 04/15/13 and she stated she did not have any policy that contained all the elements required. The findings were also presented in the exit conference on the afternoon of 10/16/13 with administration. No further documentation was provided.