ATTACHMENT 7- JAMES H. QUILLEN ABUSE OF PATIENTS MEMO.pdf

JAMES H. QUILLEN VETERANS AFFAIRS MEDICAL CENTER

(JOHNSON CITY)

MOUNTAIN HOME, TENNESSEE 37684

July 6, 2011

MEDICAL CENTER MEMORANDUM

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ABUSE OF PATIENTS

1. PURPOSE: This memorandum is published to establish policy, assign responsibilities, and provide guidance for ensuring the medical center’s compliance with the Department of Veterans Affairs’ policy prohibiting the abuse or mistreatment of patients and/or beneficiaries.

2. SCOPE: The contents of this memorandum apply to all employees of this medical center and community based outpatient clinics.

3. POLICY:

a. It is a fundamental and closely guarded policy of the Department of Veterans Affairs that no patient and/or beneficiary is to be mistreated or abused physically, psychologically, sexually, financially, or verbally by an employee. Furthermore, it is an accepted fact that each employee is entitled to a work environment which is conducive to the safe, orderly, and efficient conduct of the department’s operation. However, conflict between the department policy concerning abuse of patients and an employee’s entitlement shall not be construed as an exception to such policy, no matter the provocation or circumstances surrounding a patient incident.

b. At all stages of an investigation any employee providing information, whether the employee against whom the charges are made or witnesses, is entitled to representation. Employees who are being questioned in an investigation will be informed as to why they are being questioned and the nature of the allegation. If there is available written evidence, a copy will be provided to the employee so they can respond to the allegation.

4. ACTION/RESPONSIBILITY:

a. The definition of patient abuse is physical, psychological, sexual, financial, or verbal harm to a patient including:

(1) Any action or behavior that interferes with the patient's personal freedoms.

(2) Intentional omission of patient care.

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(3) Willful violation of patient privacy.

(4) Intimidation, harassment, or ridicule of a patient.

(5) Willful physical, emotional, or financial injury of a patient(s).

(6) Indifference or disrespect.

(7) Sexual abuse, which includes sexual assault, with or without penetration.

b. Intent is not a requirement for sustaining patient abuse. The patient’s perception of how they were treated is a vital component of the decision as to whether a patient was abused.

c. Employees, in their dealings with patients and/or beneficiaries, are responsible for:

(1) Conduct in a manner reflecting credit upon themselves and the Department of Veterans Affairs.

(2) Avoiding action that could possibly be considered as an act of abuse or mistreatment of patients.

(3) Reporting abuse or mistreatment of a patient which they witness and/or become knowledgeable of to their immediate supervisor.

(4) Reporting abusive acts toward employee(s) on the part of patients and/or beneficiaries to their immediate supervisor.

(5) Cooperating fully with any investigation or inquiry into an alleged incident of abuse or mistreatment.

d. Service chiefs are responsible for:

(1) Advising their supervisors that information relating to allegations of patient abuse is handled in strictest confidence and discussed only with parties that need to know.

(2) Reporting any complaint or evidence of abuse or mistreatment of a patient to the Chief of Staff, Associate Medical Center Director, and/or Associate Director for Patient/Nursing Services as appropriate.

(3) Working with the supervisors and Human Resources to ensure that necessary steps are taken to ensure employees and patients are in a safe work environment.

e. In accordance with the Department of Veterans Affairs regulation, the following procedures are mandatory whenever a patient, visitor, family member, or employee reports an allegation of patient abuse.

(1) In all instances of alleged patient abuse, the first employee who becomes aware of the incident will immediately report the circumstances by immediately notifying their supervisor. The supervisor will notify the proper service chief and/or supervising staff.

The employee will immediately complete an incident report (VA Form 10-2633, Report of Special Incident Involving A Beneficiary) with detailed information. The form will be given to the physician responsible for the patient's care or the physician(s) who is called to examine the patient. The physician will record a brief statement of examination of findings on the incident report. This information will be given immediately to the appropriate Executive Leadership Team member for discussion.

(2) The Service Chief will ensure an appropriate fact finding is conducted and properly documented.

(3) The pertinent Executive Leadership Team member, after discussion with Service Chief, will initiate a preliminary review of the event to determine if there is any likelihood of abuse. If patient abuse is suspected, an Administrative Board of Investigation with appropriate professional and peer representation may be conducted, if fact finding warrants.

(4) In all substantiated cases of patient abuse, appropriate leadership personnel will determine which corrective actions should be taken with guidance of Human Resources.

(5) Where physical or sexual abuse has been alleged, the employee will be temporarily reassigned to a position whose primary function does not involve patient care or routine contact with patients, pending investigation. More serious cases may dictate that the employee be placed in a non-duty with pay status, as the situation may warrant. A decision to invoke non-duty with pay status may only be made by the Medical Center Director.

(6) In cases of alleged non-physical abuse (i.e., verbal, psychological, etc.), the employee may be temporarily reassigned to a different unit or workstation other than one at which the incident occurred, pending completion of the investigation.

(7) If an allegation of abuse is not substantiated, the employee will immediately be returned to their former position.

(8) Substantiated cases of abuse will be handled by the appropriate Service Chief through Human Resources to the Medical Center Director for necessary action.

Depending on the nature and seriousness of the offense, action taken may range from an admonishment to removal. In addition, when required by VA regulations, the matter will be referred to the Office of the Inspector General (OIG) for possible prosecution under criminal statutes.

(9) Any employee who becomes aware of abuse to a patient must report it immediately to their supervisor. Failure to do so may result in initiation of appropriate disciplinary action.

5. REFERENCES: MP-5, Part 1, Chapter 752; MP-5, Part II, Chapter 8.

VA Directive 0700, Administrative Boards of Investigations.

Patient Safety Improvement VHA Handbook 1050.1.

6. RESCISSION: Medical Center Memorandum 00-08-26

7. RESCISSION DATE: July 6, 2014

8. FOLLOW-UP RESPONSIBILITY: Chief, Quality Management and Improvement Service (00Q)

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CHARLENE S. EHRET, FACHE

Medical Center Director

ABUSE OF PATIENTS