Investigating abuse: when it's one person's word against another's.

One staff member reports another staff member for abusing a confused resident, but there are no other witnesses and no physical evidence of abuse. What do you do? Many nurse executives have had to face this not so unusual occurrence, and trying to do the right thing in the face of so little evidence can be daunting. When there are no witnesses to collaborate a report of abuse and no visible signs of mistreatment, conducting a thorough inquiry is essential. The following steps can help to mitigate potential risks and improve the odds of a positive outcome for your organization:

Take quick action to protect the resident and others from further abuse. Immediately remove the alleged participant from patient access during the investigation. Some providers may choose to suspend the alleged abuser pending the outcome of the investigation, while others might decide to reassign the staff member to work in an area where there is no resident contact, such as the laundry or kitchen, and during hours when supervision is available. It is important to recognize, though, the risks that your facility might face by allowing an alleged abuser to remain in the facility during the abuse investigation, especially if supervision is not sufficient or the person is able to gain access to residents.

According to the Federal Regulation F225, 42 CFR [section]483.13(c)(2): "The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures." Reporting procedures require that authorities be notified prior to determining the outcome of an alleged violation. Most states have specific reporting procedures in place that should be followed. However, there is no requirement at the federal level for notification of the police unless a criminal act, such as rape, has occurred and most states follow this standard. Some organizations or corporations may require that the police be notified.

Begin the internal investigation immediately. As a nurse executive, you could receive an abuse report during evening or weekend hours. Nevertheless, the investigation must begin promptly. Waiting until the following morning or the start of the business week to initiate an investigation is not acceptable because it may expose residents to further potential for harm. Additionally, failure to act quickly could result in significant citations. If the DON or the administrator is not on site or available to begin the investigation, the on-duty charge nurse or supervisor should be directed to initiate the investigation by completing an incident report and/or initiating documentation on the investigative report that includes key pieces of the investigation, such as:

* details of activity that was occurring at the time of the alleged incident,

* the names and statements of staff members working on the unit at the time,

* a review of the environment,

* specifics about the resident, including a head-to-toe assessment; any visible signs or changes in behavior; and disruption to the resident or the resident's room, and

* statements or interviews from the witness, other residents, and the alleged violator (check with your state regarding specific investigative procedure requirements).

It is important to stay in close contact with the investigator, so information can be shared and further direction can be provided.

Dig deeper than the basic facts. Once the initial investigation has been completed, evaluate the credibility of both the alleged participant and the witness. This step will help you in the difficult decision-making process of determining a reasonable and justifiable outcome. Begin by separately interviewing the witness and the participant. Then compare their accounts and evaluate any discrepancies. Review past and current performance for both employees, including any disciplinary actions that either person has received. Interview peers, supervisors, residents, and family members regarding each staff member's credibility and dependability. Investigate any prior similar circumstances in which either the participant or the witness may have been involved. Determine if a situation exists that might cause the witness to convey misinformation about the alleged participant, such as a personal dispute, severed friendship, or racial or ethnic biases. Be sure to document the entire investigation thoroughly.

Take corrective action, if needed. If at the completion of the internal investigation, the witness to the alleged abuse is found to be credible, the nurse executive's greatest responsibility must remain with protecting residents--even if the alleged participant is considered a quality employee. Regulation requires that appropriate corrective action be taken.

Corrective actions may include termination or, depending on the circumstances, retaining the employee with a specific plan of action, including consistent oversight. As mentioned earlier, retaining the employee would involve significant risks, should the abuse reoccur. If you decide to retain the staff member, clearly document why the he or she remains eligible for employment and create a well-defined supervision and oversight plan. The fact that the employee has been regarded as a quality employee cannot be the only evidence considered in order to continue employment.

If at the completion of the investigation, the witness is found not to be credible, and based on the witness's reasons for communicating such grave allegations, serious disciplinary action must occur. Determining the most judicious approach to handle such a sensitive issue so that other staff members are not discouraged from reporting abuse is paramount.

Finally, as a general rule, it is always well-advised to contact the facility attorney for advice regarding internal abuse investigations and possible corrective options.

Jan Bennet, RN, NHA, is the Executive Vice-President of the American Association of Nurse Executives (AANEX). For more information, phone (877) 457-7208, e-mail jbennet@aanex.org, or visit www.aanex.org. To send your comments to the author and editors, e-mail bennet0208@nursinghomesmagazine.com.

BY JAN BENNET, RN, NHA, AMERICAN ASSOCIATION OF NURSE EXECUTIVES (AANEX)

RELATED ARTICLE: About AANEX

AANEX is a non-profit professional association representing nurse executives working in the long-term care industry. AANEX is operated by nurses for nurses and is dedicated to providing members with the resources, tools, and support they need in their specialized role of leader and manager in long-term care.

AANEX offers the nurse executive:

* The opportunity to discuss common challenges and problem-solve with peers and experts from across the country via the Executive Town Hall and online discussion groups

* Quick and easy access to current long-term care news, regulatory updates, manuals, and publications

* Weekly e-mail reminders about important dates, deadlines, and current events

* Educational programs and CEs encompassing the essential job functions of the long-term care nurse executive

* ExecExpress, a weekly newsletter addressing tough issues and frequently asked questions posed by AANEX members

AANEX is the organization chosen by successful leaders in long-term care. To join or to get more information about AANEX, visit www.aanex.org or call (877) 457-7208.