Healthcare Accreditation Certification Program Newsletter
February 2020


Patient Rights - Part Three

By: Traci Curtis RCP, HACP
In September of 2011, CMS revised the Conditions of Participation regarding patient rights. In Part 3 of this series, we'll discuss the need to protect patients from abuse or neglect.
Patients have the right to be protected from forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients or visitors. CMS defines abuse as "the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness."
Minimizing the risk of patient abuse or neglect is mission critical for a hospital, and CMS takes any allegation of such actions very seriously. Failure to have an effective approach to this issue usually results in an immediate jeopardy designation - which can lead to loss of a hospital's Medicare certification. So what constitutes an effective abuse protection program? Here's some things to consider:

Have Adequate Staffing

Your hospital must ensure that there are adequate staff on duty, especially during the evening, nighttime, weekends and holiday shifts, to take care of the individual needs of all patients. Lack of adequate qualified staff has been shown to be a correlative factor in increasing the incidence of abuse or neglect.

Screen Personnel

Persons with a record of abuse or neglect should not be hired or retained as employees. Staff - including contract staff and volunteers - should be screened to determine if they have ever been convicted of abuse or neglect.

Train Personnel

Your hospital, during its orientation program and through an ongoing training program, should provide all employees, as well as contract staff, with information regarding abuse and neglect; and related reporting requirements, including prevention, intervention and detection.

Protect the Patient

If there is any suspicion or allegation of abuse or neglect the hospital must protect the patient during any subsequent investigation. If a family member or visitor is suspected, that individual should be prohibited from contact with the patient until the investigation is concluded. If an allegation has been made against an employee or contract worker, then that individual should be removed from all patient contact (not just the patient involved in the allegation), until the investigation is concluded.

Investigate Quickly

Your hospital must ensure that internal investigations into all allegations of abuse, neglect or mistreatment are conducted in a timely, thorough, and objective manner. There should be no undue delay between the time an allegation is made, and when the investigation is initiated.


Your hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law.
Fortunately, the incidence of patient abuse or neglect in a healthcare setting is rare. Unfortunately, it does happen. When it does, following these guidelines will help assure that your hospital is protected as well as your patient.
Join us next month for Part 4 on our patient rights series as we look at advance directive.
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