Page 115 - Compliance Workbook June

• The superv1s1on of staff to identify inappropriate behaviors, such as using derogatory
language, rough handling, ignoring residents while giving care, misdirecting residents to meet
their activities of daily living needs in an inappropriate manner; and

• The assessment, care planning, and monitoring of residents with needs and behaviors which
might lead to conflict or neglect, such as residents with a history of aggressive behaviors, or
behaviors such as entering other residents' rooms, self-injurious behaviors, communication
disorders, and those residents who require heavy nursing care and/or are totally dependent on
staff.

IDENTIFICATION:
It is the responsibility of the Administrator and/or Nursing Services to identify events such as suspicious
bruising of residents, occurrences, patterns, and trends that may constitute abuse/neglect and to determine
the direction of the investigation.

INVESTIGATION:
The Administrator and/or the Director of Nursing Services are responsible for initiation of the
investigation immediately upon notification of alleged event or findings. Facility will document
investigation findings, including witness statements, corrective actions, and conclusions in administrative
file. Facility will be responsible to notify the resident, resident's legal representative or interested family
member of any investigational findings and facility outcomes as allowable within privacy standards.

PROTECTION:
The Administrator and/or Director of Nursing Services are responsible for taking immediate action and
ensuring the resident is protected from harm during the investigation of the alleged incident. The
Administrator and the Director of Nursing are also responsible for ensuring the resident is protected from
harm by conducting pre-employment reference checks on all facility employees and requiring
documentation of such checks from vendors supplying persons who provide services to residents.
Reference checks include; a Criminal Background Check as prescribed by federal and state regulations,
checking the state registry to verify licensure, checking state registry to verify that there is no
disqualification against the employee, and verifying previous employment with at least two (2) former
employers. New employees are in-serviced on Resident's Rights and Resident Abuse and Neglect at
orientation and all employees participate in biannual Resident's Rights and Resident Abuse and Neglect
in-services to assure they are aware of the importance of these policies.

REPORTING:
It is the responsibility of every employee of this facility to report the following types of alleged
violations:
1. In the event an employee witnesses or has knowledge of any abuse/neglect situation
occurring in the facility, that employee is to immediately notify the Supervisor who will
notify the Administrator and/or Director of Nursing Services
2. An "injury of unknown source" must be reported to the Administrator and/or Director of
Nursing when both the following conditions exists:
a. The source of the injury was not observed by any person or could not be
explained by the resident; and
b. The injury is suspicious because of the extent of the injury, location of the injury
number of injuries observed at one particular point in time or the incidence of
injuries over time.

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