The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HOPEBRIDGE HOSPITAL 5556 GASMER DRIVE HOUSTON, TX Aug. 11, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview and record review August 10-11, 2016, the governing body failed to ensure that:


1. The patient's right to receive care in a safe setting was upheld and

2. An effective data-driven quality assessment and performance improvement program to measure, analyze and track occurrences involving abuse of patients by staff was maintained.


The identified practices resulted in actual harm to 8 patients (Patient #1, #2, #3, #4, #7, #8, #9, Patient #10) and presents a likelihood of harm to all current (census of 45) and potential patients admitted for psychiatric treatment.


Based on interviews and record review, the facility failed to ensure the right of patients to receive care in a safe setting as evidenced by numerous complaints of physical abuse by staff that resulted in documented bruises, scratches, rough handling by staff, and an against medical advice discharge. Investigations into these occurrences by the Risk Manager ranged from incomplete to nonexistent. This failed practice resulted in patients not being protected. This poses a risk for current and potential patients with behavioral problems on the adult, adolescent and children ' s psychiatric units. Refer to CFR 482.13 [A-0115] [A-0194].


Based on interviews and record review, the facility failed to ensure the Director of Quality/Risk Management maintained an effective data-driven quality assessment and performance improvement program. Investigation into complaints of abuse by the Risk Manager ranged from incomplete to nonexistent. The Quality Director ' s reporting of abuse to the governing body was not an accurate representation of the prevalence of critical events occurring in the facility. This failed practice has resulted in patients continuing to be exposed to abusive situations. This poses a risk for current and potential patients with behavioral problems on the adult, adolescent and children ' s psychiatric units. Refer to CFR 482.21 [A-0263].
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interviews and record review, the facility failed to ensure the right of patients to receive care in a safe setting as evidenced by numerous complaints of physical abuse by staff that resulted in documented bruises, scratches, rough handling by staff, and an against medical advice discharge. Investigations into these occurrences by the Risk Manager ranged from incomplete to nonexistent. This failed practice resulted in patients not being protected. This poses a risk for current and potential patients with behavioral problems on the adult, adolescent and children's psychiatric units.


The cumulative effect of the deficient practices were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury and possible subsequent death.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record review, the facility failed to ensure a safe, humane setting by adequately investigating allegations of physical abuse for 8 of 8 patients (Patient #1, #2, #3, #4, #7, #8, #9, and Patient #10). This was evidenced by:

1. The Risk Manager (Personnel #53) unsubstantiated the allegation of physical abuse made by Patient #1 even though the investigation contained erroneous information. The completion of the Administrative/Quality/Risk form (the facility ' s last step in the closing of an investigation) had not been done.
2. The Patient Advocate (Personnel #76) substantiated physical abuse of Patient #2 but failed to make an occurrence report or involve the Risk Manager (Personnel #53). The Administrative/Quality/Risk form had not been done.
3. Patient #3 was discharged against medical advice at the insistence of his mother after he alleged physical abuse by a staff member. There was no investigation by the Risk Manager (Personnel #53). The Administrative/Quality/Risk form had not been done.
4. Patient #4 alleged physical abuse. Patients #5 and #6 provided written statements as eye witnesses of the allegations. The Risk Manager (Personnel #53) neither conducted an investigation nor generated an occurrence report, but deemed the allegation as " probably substantiated. " The Administrative/Quality/Risk form had not been done.
5. The investigation into Patient #7 ' s complaint of physical abuse was inadequate. The Risk Manager (Personnel #53) failed to identify the hands-on intervention of an untrained housekeeper as a breech in protocol. The occurrence report was also incomplete. The Administrative/Quality/Risk form had not been done.
6. Patient #8 sustained documented injuries during a behavioral intervention. The Risk Manager (Personnel #53) failed to adequately investigate the incident by interviewing the patient prior to the patient ' s discharge. The Administrative/Quality/Risk form had not been done.
7. The Risk Manager (Personnel #53) knew nothing of allegations of abuse by Patient #9 ' s foster mother or of it being unsubstantiated on a complaint form by the Patient Advocate. An occurrence report was not generated. The Administrative/Quality/Risk form had not been done.
8. The Risk Manager (Personnel #53) knew nothing of allegations of abuse by Patients #10 or of it being unsubstantiated on a complaint form by the Patient Advocate (Personnel #76). An occurrence report was not generated. The Administrative/Quality/Risk form had not been done.
These failed practices shaped and perpetuated an unsafe setting for the patients.

Findings included:

Patient #1.

Record review of Nursing Assessment Note by RN #57 dated 07/25/2016 at 0600 revealed: Patient #1, a [AGE]-year-old male became threatening, balling up his fists and dancing around during the Initial Nursing Assessment.

In an interview with Patient #1 on 08/10/2016 at 1450, he stated:
He was answering the nurse ' s questions and " staff got aggressive " ;
There was arguing, help came and a staff person choked him from behind;
He couldn ' t breathe from the choke hold, his right arm was injured and MHT #63 hit him in the eye.

In an interview with MHT #63 on 08/10/2016 at 1505, he stated he and MHT #72 took Patient #1 to the ground. He also stated MHT #72 " grabbed " Patient #1 " from behind across the chest. "

In an interview with MHT #72 on 08/11/2016 at 0815, he stated he put his arms around Patient #1 using " CPI [Crisis Prevention Institute] interventions. "

In an interview with Patient Advocate #76 on 08/10/2016 at 1211, he stated he spoke with RM #53 about Patient #1. " She was just informing me about the incident. " He also stated he spoke with the nursing supervisor about the need to investigate and get statements.

In an interview with RM #53 on 08/10/2016 at 1105, she stated:
During her investigation, she had not interviewed Patient #1 or looked at his eye.
She could not name the key players involved in Patient #1 ' s code.
She had not taken statements from MHT #63, MHT #72, Security #73 or RN Supervisor #64.
She had taken a statement from RN #75, " the nurse who admitted " Patient #1. [RN #57 actually admitted Patient #1.]
" I got the wrong nurse ' s name. "
Her conclusion was that the allegation of being choked could not be substantiated.
The investigation was incomplete and still open.
[When asked about her inability to answer questions related to the investigation,] " I relied on other people to do most of the investigation. I didn ' t do what I should have done in a timely manner. I ... didn ' t get in there to investigate this as I should have done. "
She allows herself 2-3 weeks to complete an investigation, " no more than 30 days. "


Patient #2.

Record review of Pre-Admission Exam & Certification by MD #78 dated 12/10/2015 at 2019 revealed a 9 year-old female with a history of neglect by parents, parental drug abuse and suspected physical abuse.

Record review of Nursing Assessment Note by RN #80 dated 12/17/2015 at 1140 revealed: " Unpredictable mood ... Constantly oppositional and defiant. Impulse control poor ... physically aggressive towards peers ... Easily agitated ... Always wanting everything to go her way, otherwise, she will throw tantrums. "

Record review of the Grievance/Concern Dashboard revealed that an incident of patient abuse by staff toward Patient #2 was " substantiated. "

Record review of the Concern/Issue Resolution Form by Patient Advocate #76 dated 12/17/2015 at 1218 revealed:
Certified Recreation Therapist Specialist (CTRS) #79 stated RN #80 physically abused Patient #2;
Patient Advocate #76 informed RN Supervisor #60, CNO #51, Human Resources and CEO #52 of the allegation;
RN #80 was placed on suspension pending an investigation;
There was no statement from RN #80

In an interview with CTRS #79 on 08/11/2016 at 1000, she stated:
RN #80 was yelling at Patient #2 and pushed Patient #2 who fell to the floor;
RN #80 then " pulled the patient by her sports bra and slung her back into her room " ;
" The child was crying hysterically " ;
She stepped in at this point to stop RN #80;
RN #80 asked, " What should I do " ; and
CTRS #79 told RN #80 to call a code. CTRS #79 then reported the incident to Patient Advocate #76.

In an interview with Patient Advocate #76 on 08/11/2016 at 1020, he stated he did not inform Risk Manager #53 of the abuse of Patient #2 by RN #80. He also stated he did not report this to the state, adding " Human Resources said she resigned. "

In an interview with RM #53 on 08/11/2016 at 1000, she stated she did not report the incident to the state, adding, she didn ' t know about it but should have been informed of it. She also stated she did not investigate the abuse and had no occurrence report.

In an interview with CCO/CNO #51 on 08/11/2016 at 1000, she stated RN #80 should have been reported Texas Board of Nursing (TBON), adding she would immediately report this to the TBON.


Patient #3.

Record review of Progress Note by MD #84 dated 06/29/2016 at 0900 revealed Patient #3 to be a [AGE]-year-old male. " Patient says staff member ' abused ' him last night by throwing him on the bed after he refused to ' comply ' . "

Record review of Progress Note by RN #83 dated 06/29/2016 at 2025 revealed a phone call from Patient #3 ' s mother. The mother stated her son reported " a male staff pushed him on his bed and restrained him last night on admission. " Patient #3 was discharged against medical advice (AMA) at the mother ' s insistence. Patient Advocate #76, RM #53 and CCO/CNO #51 were notified.

In an interview with RM #53 on 08/10/2016 at 1415, she stated an investigation had not been started on Patient #3 ' s accusation of physical abuse. She also stated she had neither identified the MHTs working on the evening of the allegation nor had she obtained statements from staff. She concluded by stating there was no further follow-up from Patient Advocate #76.


Patient #4.

Record review of a Registration Record revealed Patient #4 was a [AGE]-year-old male admitted on [DATE].

In an interview with RM #53 on 08/10/2016 at 1415, she stated she had a file on Patient [she gave the first name of the patient] who alleged abuse by a tech on 05/04/2016. [Upon reviewing the file, it was noted that there was no last name of the patient.] She stated she did not know the last name of the patient or the names of the staff involved in the incident. When questioned how one does an investigation without the name of the patent, she had no answer. [She researched census sheets and identified the patient as Patient #4.] She also stated:
There had been no investigation conducted;
There was no occurrence report on the alleged physical abuse;
She had two written statements from patients that witnessed the alleged abuse, and
The alleged abuse was " probably substantiated. "

Record review of a written statement by Patient #5 dated 05/05/2016 at 2130 revealed MHT #86 " grabbed " Patient #4 " by the shirt and neck and he blatantly threw him back into the wheel chair and he looked down the hall to see if anyone was observing him and he and I made eye contact and I told him, ' Yea, I ' m looking at you. ' I informed the nurse on duty. "

Record review of a written statement by Patient #6 dated 05/04/2016 at 1930 revealed MHT #86 " rushed at " Patient #4 " like he was going to hurt him. He told him that he was going to kick him in the face. " Patient #4 " moved back and started to cry. I really think something should be done. "

In an interview with CCO/CNO #51 on 08/10/2016 at 1500, she stated:
She terminated MHT #86;
He did not return to the hospital for his final interview so a statement from him about the alleged abuse could not be obtained; and
She did not know RM #53 did not conduct an investigation.


Patient #7.

Record review of an Identification Label revealed Patient #7 was a [AGE]-year-old female admitted on [DATE].

In an interview with Patient # 7 on 07/12/2016 at 1450, she stated she was choked by Housekeeper #87 during a code situation.

Record review of written statement by Patient #7 dated 07/12/2016 revealed she became frustrated and angry with her case worker, which resulted in an injection. She kicked, screamed and pushed. She ran to the end of the hallway. Housekeeper #87 put her hand on my neck and choked me half to death. " " I have scratches and bruises on my neck and I can ' t swallow that good. "

Record review of a written statement by Housekeeper #87 dated 07/14/2016 [no time] revealed: On 7/12/16 she was cleaning rooms. She witnessed the restraint of Patient #7. She went to her cart to keep Patient #7 from the supplies on the cart. Patient #7 hit the double doors. Housekeeper #87 asked her to calm down and stated, " You are going to get a shot if you don ' t stop. " Patient #7 " started kicking me then and I walked off. And I said, ' I ' m gone; she ' s not going to hurt me. ' " Housekeeper #87 returned to cleaning. At the nurse ' s station, Patient #7 stated she wanted to talk to MHT #89 and Housekeeper #87. " I was trying to get her to her room. I reached for her, she said, ' DON " T TOUCH ME. ' And I moved back away from her. "

Record review of the personnel file of Housekeeper #87 revealed no CPI training.

In an interview with CCO/CNO #51 and CEO #52 on 08/12/2016, they stated Housekeeper #87 should not have been a part of the team assembled to de-escalate Patient #7.

In an interview with RM #53 on 08/10/2016 at 1430, she stated:
She was investigating an incident involving allegations by Patient #7 that she was hit and choked by staff resulting in " scratches and bruising " ;
Photographs confirm that Patient Tara Tober had scratches and bruises on her neck on 07/12/2016;
She had not known about, investigated or addressed the interventions by Housekeeper #87 with Patient #7; and
The occurrence report was incomplete.


Patient #8.

Record review of an Identification Label revealed Patient #8 was a [AGE]-year-old male admitted on [DATE].

Record review a written statement about Patient #8 by MHT #88 [no date or time] revealed: " I am writing this letter in regards to a patient having marks on his body. In an attempt to restrain the patient he began to elope. After not being able to elope he began swinging, kicking, spitting and attempting to bite the employees. Patient resisted for at least 30 minutes in an attempt to restrain him by the CPI method. There is no direct answer on how a patient gets bruises while resisting to be restrained. In an attempt to restrain a patient, employees and patients are at risk to sustain injuries. "

Record review of Follow-Up Note by RN Supervisor #60 dated 07/14/2016 at 1020 revealed: Patient #8 alleged a left shoulder injury " during physical hold in Intake. " Patient #8 had multiple superficial scratches to bilateral arms and several small abrasions to back of neck. Patient #8 stated the scratches, abrasions and left shoulder pain are a result of the physical hold. " [Four photographs of scratches attached to note.]

In an interview with RM #53 on 08/10/2016 at 1430, she stated:
She reviewed this incident involving Patient #8on 07/15/2016 and was investigating it; and
She had not spoken with the patient or staff involved in the incident.


Patients #9 and #10.

Record review of the Grievance/Concern Dashboard revealed:

1. On 02/25/2016 [no time], the foster mother of Patient #9 " reported alleged staff abuse. " This was " unsubstantiated " after staff was interviewed. The " CCO to follow up due to lack of witness. "

2. On 03/08/2016 [no time], Patient #10 alleged being hit in the throat by staff. This was " unsubstantiated " after staff and the patient were interviewed and statements given by staff.

In an interview with RM #53 on 08/10/2016 at 1430, she stated she did not have occurrence reports on Patient #9 or Patient #10 and that she knew nothing of the allegations or investigation by Patient Advocate #76. She also stated she could not provide any documentation of an investigation.


Additional Interviews.


In an interview with Patient Advocate #76 on 08/10/2016 at 1520, he stated:

He may get a complaint of physical abuse on a complaint form;

He notifies the nursing supervisor of complaints of physical abuse;

Once he finds the complaint substantiated, he notifies the Risk Manager;

He has not always involved the Risk Manager in the investigation of complaints of abuse.


In an interview with CEO #52 on 08/11/2016, at 1600, he stated that a red file [a critical event file] is closed out when an Administrative/Quality/Risk Review is completed. [He presented an example of an Administrative/Quality/Risk Review.]


Record review of an Administrative/Quality/Risk Review form revealed the following elements: Overview, Findings, Assessment, Overall Impression, Plan and the Risk Manager's signature.


Record review of critical event files for Patient #1, #2, #3, #4, #7, and Patient #8 did not have an Administrative/Quality/Risk Review.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record review, the facility failed to ensure the right to safe implementation of restraint as evidenced by an untrained staff member inserting herself into a behavioral intervention for 1 (Patient #7) of 8 patients (Patient #1, #2, #3, #4, #7, #8, #9, and Patient #10).


Findings included:


Record review of an Identification Label revealed Patient #7 was a [AGE]-year-old female, admitted on [DATE].


In an interview with Patient # 7 on 07/12/2016, at 1450, she stated she was choked by Housekeeper #87 during a code situation.


Record review of written statement by Patient #7 dated 07/12/2016, revealed she became frustrated and angry with her case worker, which resulted in an injection. She kicked, screamed and pushed. She ran to the end of the hallway. Housekeeper #87 "put her hand on my neck and choked me half to death." "I have scratches and bruises on my neck and I can ' t swallow that good."


Record review of a written statement by Housekeeper #87 dated 07/14/2016 [no time] revealed: On 7/12/16, she was cleaning rooms. She witnessed the restraint of Patient #7. She went to her cart to keep Patient #7 from the supplies on the cart. Patient #7 hit the double doors. Housekeeper #87 asked her to calm down and stated, "You are going to get a shot if you don't stop." Patient #7 "started kicking me then and I walked off. And I said, 'I' m gone; she's not going to hurt me.'" Housekeeper #87 returned to cleaning. At the nurse's station, Patient #7 stated she wanted to talk to MHT #89 and Housekeeper #87. "I was trying to get her to her room. I reached for her, she said, 'DON'T TOUCH ME.' And I moved back away from her."


Record review of the personnel file of Housekeeper #87 revealed no CPI [Crisis Prevention Institute] training.


In an interview with CCO/CNO #51 and CEO #52 on 08/12/2016, they stated Housekeeper #87 should not have been a part of the team assembled to de-escalate Patient #7.
VIOLATION: QAPI Tag No: A0263
Based on interviews and record reviews, the facility failed to ensure the Director of Quality/Risk Management maintained an effective data-driven quality assessment and performance improvement program. Investigation into complaints of abuse by the Risk Manager ranged from incomplete to nonexistent. The Quality Director's reporting of abuse to the governing body was not an accurate representation of the prevalence of critical events occurring in facility. This failed practice has resulted in patients continuing to be exposed to abusive situations. This poses a risk for current and potential patients with behavioral problems on the adult, adolescent and children's psychiatric units.


The cumulative effect of the deficient practices were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury and possible subsequent death.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and records review, the facility failed to ensure the Quality Director tracked adverse events by accurately reporting occurrences of physical abuse for 6 (Patient #1, #2, #3, #4, #9, and Patient #10) of 8 patients (Patient #1, #2, #3, #4, #7, #8, #9, and Patient #10) as evidenced by:


1. Though the investigation of Patient #1 was incomplete and contained erroneous information, it had been unsubstantiated by the Risk Manager.

2. The Patient Advocate substantiated physical abuse of Patient #2 but failed to make an occurrence report or involve the Risk Manager.

3. Patient #3 was discharged against medical advice at the insistence of his mother because of alleged physical abuse with no investigation by the Risk Manager.

4. Though Patient #4 alleged physical abuse documented by two witnesses, an investigation was not conducted, an occurrence report was not completed and the occurrence was deemed as "probably substantiated."

5. The Risk Manager knew nothing of allegations of abuse by Patient #9's foster mother or of it being unsubstantiated on a complaint form by the Patient Advocate instead of an occurrence report.

6. The Risk Manager knew nothing of allegations of abuse by Patients #10 or of it being unsubstantiated on a complaint form by the Patient Advocate instead of an occurrence report.


This failed practice resulted in inaccurate reporting of patient injuries that occurred during behavioral interventions, as well as allegations of physical abuse made by patients.


Findings included:


Patient #1.

In an interview with Patient #1 on 08/10/2016 at 1450, he stated:

He was answering the nurse ' s questions and "staff got aggressive;"

There was arguing, help came and a staff person choked him from behind;

He couldn't breathe from the choke hold, his right arm was injured and MHT #63 hit him in the eye.


In an interview with Patient Advocate #76 on 08/10/2016, at 1211, he stated he spoke with RM #53 about Patient #1. "She was just informing me about the incident." He also stated he spoke with the nursing supervisor about the need to investigate and get statements.


In an interview with RM #53 on 08/10/2016, at 1105, she stated:

During her investigation, she had not interviewed Patient #1 or looked at his eye.

She had not taken statements from key staff involved in the incident.

Her conclusion was that the allegation of being choked could not be substantiated; however, the investigation was incomplete and still open.

She relied on other people to do most of the investigation and "didn't do what I should have done in a timely manner."


Patient #2.

Record review of Pre-Admission Exam & Certification by MD #78 dated 12/10/2015, at 2019, revealed a 9 year-old female with a history of neglect by parents, parental drug abuse and suspected physical abuse.


Record review of the Grievance/Concern Dashboard revealed that an incident of patient abuse by staff toward Patient #2 was "substantiated."


In an interview with CTRS #79 on 08/11/2016, at 1000, she stated:

RN #80 yelled at and pushed Patient #2 who fell to the floor;

RN #80 then "pulled the patient by her sports bra and slung her back into her room;"

"The child was crying hysterically;"

She stepped in at this point to stop RN #80 and reported the incident to Patient Advocate #76.


In an interview with Patient Advocate #76 on 08/11/2016, at 1020, he stated he did not inform Risk Manager #53 of the abuse of Patient #2 by RN #80.


In an interview with RM #53 on 08/11/2016, at 1000, she stated she did not investigate the abuse and had no occurrence report.



Patient #3.

Record review of Progress Note by MD #84 dated 06/29/2016, at 0900, revealed Patient #3 to be a [AGE]-year-old male. "Patient says staff member 'abused' him last night by throwing him on the bed after he refused to 'comply'."


Record review of Progress Note by RN #83 dated 06/29/2016, at 2025, revealed a phone call from Patient #3's mother. The mother stated her son reported "a male staff pushed him on his bed and restrained him last night on admission." Patient #3 was discharged against medical advice (AMA) at the mother's insistence. Patient Advocate #76, RM #53 and CCO/CNO #51 were notified.


In an interview with RM #53 on 08/10/2016 at 1415, she stated an investigation had not been started on Patient #3's accusation of physical abuse.


Patient #4.


Record review of a Registration Record revealed Patient #4 was a [AGE]-year-old male, admitted on [DATE].


In an interview with RM #53 on 08/10/2016, at 1415, she stated she had a file on Patient [first name of patient was given] who alleged abuse by a tech on 05/04/2016. She stated she did not know the last name of the patient or the names of the staff involved in the incident. When questioned how one does an investigation without the name of the patent, she had no answer. She also stated:

There had been no investigation conducted;

There was no occurrence report on the alleged physical abuse;

She had two written statements from patients that witnessed the alleged abuse, and

The alleged abuse was " probably substantiated. "



In an interview with CCO/CNO #51 on 08/10/2016, at 1500, she stated she did not know RM #53 did not conduct an investigation.


Patients #9 and #10.


Record review of the Grievance/Concern Dashboard revealed:

1. On 02/25/2016, [no time], the foster mother of Patient #9 "reported alleged staff abuse." This was "unsubstantiated" after staff was interviewed.

2. On 03/08/2016, [no time], Patient #10 alleged being hit in the throat by staff. This was "unsubstantiated" after staff and the patient was interviewed and statements given by staff.


In an interview with RM #53 on 08/10/2016, at 1430, she stated she did not have occurrence reports on Patient #9 or Patient #10 and that she knew nothing of the allegations or investigation by Patient Advocate #76. She also stated she could not provide any documentation of an investigation.


Additional Interviews.


In an interview with RM #53 on 08/11/2016, at 1500, she stated the Quality Assessment Performance Improvement statistics cannot be accurate if:

She does not receive all of the Occurrence Reports;

Occurrence Reports are not generated from complaints;

All incidents of alleged abuse are not reported to Risk; or

There is not ongoing communication between her and the Patient Advocate.
She further stated the data she has reported in Quality has not reflected all occurrences of alleged abuse.


In an interview with Patient Advocate #76 on 08/10/2016, at 1520, he stated he may get a complaint of physical abuse on a complaint form and he has not always involved the Risk Manager in the investigation of complaints of abuse.