Date of Last Review 10/14/10
Date of Last Review 10/13/11
SME: Patient Relations Manager
UTHCPC employees have a legal duty and ethical obligation to report suspected
abuse, exploitation or neglect of UTHCPC patients. This extends to the reporting
of harmful practices by other caregivers, including hospital employees, clients,
volunteers, consultants, contract affiliates, and other agents. Prompt cooperation with internal investigations, including submission of verbal and written statements, is compulsory.
Anyone reporting in good faith is exempt from civil and criminal liability and is protected from retaliation in the workplace.
The following are required by law when individuals apply for work:
 | The law requires employers to report any sexual exploitation or other abuses by former employees to another employer requesting references. |
| An employer may become liable for failing to make sufficient inquiries about an employee's work history. |
| UTHCPC reports an employee's history of patient abuse or neglect to prospective employers. |
The suspicion written statement includes the following:
| Date, time, and place of occurrence |
| Description of occurrence |
| Description of injury (if any) to the patient |
| Names of any persons who witnessed or have knowledge of the occurrence |
The written investigation statement includes the following:
| Date, time, and place of occurrence |
| Direct observation of occurrence |
| Signature of person writing statement |
| Names of any other persons who witnessed or have knowledge of the occurrence |
Employees must report any pregnancy of a patient resulting during her hospital stay as abuse/neglect/exploitation.
If the attending physician examines an injured patient and suspects that the injury is the result of abuse, the physician must refer them to Patient Relations and that department investigates the incident.
Perpetrator unknown is used when an evidence of the abuse exists but positive identification of the person(s) responsible is unknown.
Allegations involving clinical practice are reviewed as follows:
| If an allegation involves actions of a clinical practitioner (ex. MD, RN, LVN), hospital administration, in conjunction with Patient Relations, Medical Director or Director of Nursing, determines whether the allegation involves the clinical practice of the practitioner. |
| If a determination is made that the allegation does involve the clinical practice of the practitioner, the allegation is referred to the appropriate administrator for peer review. |
| If the abuse/neglect does not involve clinical practice, Patient Relations pursues an investigation. |
This table describes the process of reporting and investigating suspected abuse/neglect/exploitation at UTHCPC:
Stage |
Description | ||||||
1 |
Each employee who suspects or has knowledge of or is involved in an allegation must report the incident to Patient Relations immediately no later than 1 hour after the incident. | ||||||
2 |
The reporting employee must notify the physician and nursing supervisor who will review the suspicions and examine the patient immediately no later than 1 hour after the incident. | ||||||
3 |
The physician and nursing supervisor note their findings in the medical record and on the UTHCPC Patient Relations Patient Injury/Incident Report form. | ||||||
4 |
The physician completes and forwards the UTHCPC Patient Relations Patient Injury/Incident Report(s) to Patient Relations. | ||||||
5 |
The reporting employee and employees involved in the investigation sign and submit their written statement to Patient Relations within 24 hours. | ||||||
6 |
If allegations of abuse/neglect/exploitation are found substantial after a detailed investigation, the Patient Relations office notifies the administrator and the employee's immediate supervisor. | ||||||
7 |
Patient Relations completes the Abuse/Neglect/Exploitation Investigation and reports quarterly to the Texas Department of State and Health Services, Family & Protective Services unit. | ||||||
8 |
If abuse/neglect/exploitation is true, then the administration takes action that might include termination of the person who committed abuse/neglect/exploitation depending on the following.
|
The following conditions will result in closing the investigation:
| If at any point during the investigation it become apparent that the allegation does not have any factual basis, Patient Relations closes the investigation as unfounded with the approval of administration. |
| If no important evidence was found to indicate that an allegation should or should not be confirmed, the result of the investigation is inconclusive. |
Patient Relations keeps the investigation reports for five years after the investigation has been closed.
See Abuse/Neglect/Exploitation Definitions
If you have questions regarding the contents of this site please contact the
Policies and Procedures Committee.
If you experience any technical problems please contact the MIS Department.
