Protect: If a resident is actively being harmed, stop the person and ensure your resident is safe from further harm.
Report: Report the abuse/neglect or suspected abuse/neglect to a supervisor immediately.
Definition of immediately: “without lapse of time; without delay; instantly; at once”
For direct care staff this means, once you have ensured the resident is safe, you go to your nurse in charge, house charge or unit manager and report the incident or suspicion of harm.
For licensed staff this means you notify your unit manager and house charge upon receiving the report from other staff. This should be completed within minutes of the actual harm or from the time the person became suspicious of potential resident harm.
Why is it so important not delay reporting, even if it is done within the same day/shift?
Every minute/hour/ day that reporting is delayed; it is potential time for the resident to be abused/neglected or for the abuser to harm another individual. Also, our state regulations are very strict in the time allotted for reporting to our state agencies.
Document: Documentation is completed after the resident is safe and received medical treatment if needed and a verbal report has been made to the appropriate supervisor (Nurse Manager, House Charge) who will notify the administrative staff and/or state agencies. Documentation must be thorough. It includes names of suspected abuser, witnesses (includes staff, residents, visitors), date and time the event occurred or was suspected, and all specific details of what happened, what was heard, what was said, what was seen. Each person who verbally reports or is listed as a witness needs to complete the documentation as soon as possible after the verbal report is given.