It’s change of shift, and the outgoing nurse certified nurse assistant (CNA) casually mentions to the incoming CNA that Mrs. J, a 73-year-old resident with dementia, is more confused than usual. The outgoing CNA relays comments that Mrs. J made throughout the shift about being held in her room against her will.
Mrs. J also told the CNA that she wanted to leave the room before her husband returned to punish her and eat all her food, as he always did. Mrs. J is making allegations of abuse, but the CNA is attributing them to her confusion.
Unfortunately, such a scenario is not uncommon, and if it’s not taken seriously by staff, there can be negative consequences for the resident, the staff, and the skilled nursing care center.

Taking a Closer Look

With the new interpretive guidelines and the renumbered and realigned F-tags, effective Nov. 28, 2017, now is the time to take a close look at facility processes for preventing, reporting, investigating, and correcting abuse and neglect.

In its YouTube video, Long Term Care: Overview of Revised Interpretive Guidance, the Centers for Medicare & Medicaid Services highlights key changes to several sections of the revised interpretive guidance, including §483.12 Freedom From Abuse, Neglect, and Exploitation. This section now has 10 F-Tags associated with it, and a citation for any one of them could lead to a determination of substandard quality of care.

Actions to Protect and Prepare

Here are 10 actions that nurse leaders should consider taking when reviewing their abuse, neglect, and exploitation procedures to better protect residents and prepare for the next survey.

1. Know the new F-tags. Tags F600, F602, F603, F604, F605, F606, F607, F608, F609, and F610 all address abuse. These revised tags significantly expand the definitions of abuse and the protections for residents. They also articulate different time frames for reporting suspicion of a crime and reporting alleged violations.

2. Incorporate the new definitions into facility policies. It is likely that the new definitions will affect a range of policies, including abuse prevention, allegation reporting, and protection of residents during investigations. As always, staff should be promptly reeducated on the updated policies.

3. Train staff members to recognize abuse, neglect, exploitation, and misappropriation of resident property. Not only should staff be reeducated on updated care center policies, staff must be able to identify allegations of abuse and must take them seriously.

This can be more challenging than it sounds. For example, when a resident has dementia or is experiencing confusion, staff may not realize that the resident’s allegations still need to be reported and investigated. Instead, staff may be inclined to brush the allegations off, blaming them on the resident’s confusion.

In the original scenario, it is possible that physical, mental, verbal, and psychological abuse, as well as abuse through seclusion and through deprivation of goods or services, are all occurring. Both CNAs should recognize that further investigation is required. Training should be repeated annually at a minimum.

4. Thoroughly review with all staff the policies and procedures for the investigative process. Staff should be confident about when and to whom to report resident allegations so that a timely investigation can occur. In the scenario above, the CNA would, at a minimum, report the information to the charge nurse, who should report the situation to the administrator and/or other center leadership as required by company policy. An investigation should be started immediately.

5. Thoroughly review with all staff the facility’s policies, procedures, and process for reporting suspicion of a crime. In cases where allegations require a criminal investigation, there are specific state and federal reporting requirements for crimes occurring in the center that all staff should be aware of.

For example, because a crime is defined by the laws of the applicable political subdivision where the care center is located, per Appendix PP of the State Operations Manual (SOM) on page 132, facility leaders may need to meet with local law enforcement agencies. Staff should be familiar with these processes.

Care center leaders also need to be aware that there is a separate requirement related to reporting all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and reporting the results of all investigations. (Appendix PP of the SOM provides a side-by-side comparison of requirements for reporting suspicion of a crime and reporting alleged abuse, on page 144).

6. Provide annual training on all of it for all staff. The regulations specifically require facility leaders to offer annual training that reviews the definitions of abuse, neglect, exploitation, and misappropriation of resident property and the processes for reporting and investigating allegations. Even though not all staff may be directly involved in the reporting or investigation of abuse, they still need to be aware of the steps in the process, including interviews, observations, and the involvement of law-enforcement agencies.

7. Conduct a mock abuse drill. Conducting a mock drill allows care center leaders to see staff responses, identify areas of confusion, and offer education and training that specifically address the areas where the policy and procedure were not followed.

8. Practice the action steps in response to abuse, neglect, exploitation, and misappropriation of resident property. According to Appendix PP and the final interpretive guidelines, facility leaders must:

Thoroughly investigate the alleged violation; Prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress; and Take appropriate corrective action, as a result of investigation findings.

By working through these action steps with staff, leaders can be confident that their staff will be ready when it’s time to put training into action.

9. Review and assess current admission processes. Specifically, the decision-making team should assess the facility staff’s ability to care for individuals who may pose a safety risk to themselves or others through resident altercations. When a resident with dementia becomes upset and strikes another resident, this may fit the definition of abuse. According to the regulation, the definition of abuse is the willful infliction of injury, with “willful” meaning that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Make sure staff can care for the types of admissions accepted into the center.

10. Teach staff how to respond to challenging situations. Staff need to receive training not only on what abuse is but also on how to respond to delicate situations without being reactive or retaliatory. The updated regulation clearly states that facility leaders will be responsible for the actions of their staff even in situations when residents become combative.

Taking the Right Steps

It is important to remember that a center’s leaders are responsible for the safety of the residents they have accepted. Through training and education, leaders can help staff on the front lines of care to be more attuned to the residents they care for, encouraging them to actively listen when residents express distress that could be the result of abuse.

Effective training and education can empower staff to confidently take the proper steps when an allegation of abuse presents itself, rather than dismissing it. When it comes to abuse, training all staff to be resident advocates will protect residents and prevent F-tag citations.
Amy Stewart, RN
Amy Stewart, RN, DNS-MT, QCP-MT, RAC-MT, is curriculum development specialist at the American Association of Directors of Nursing Services. She can be reached at