Abuse and/or Neglect Assessment Responsibilities

TXMHMR definitions

Date of Last Review 8/13/09
SME: Director of Financial Operations

UTHCPC defines abuse, neglect, and exploitation by adopting the TXMHMR definitions set out in the Texas Administrative Code, 40 TAC 710 and 25 TAC 404. The State of Texas has three statutes that establish the criteria for identifying and reporting abuse or neglect as follows:

Chapter 161, Subchapter L of the Texas Health and Safety Code "Abuse, Neglect and Unprofessional Conduct in Health Care Facilities"

Chapter 34 of the Texas Family Code "Report of Child Abuse"

Chapter 48 of the Texas Human Resource Code, "Protective Services for the Elderly"

Employee responsibility

UTHCPC employees are required to assess and report suspected and alleged cases of abuse and neglect to the appropriate authorities, see Reporting Suspected Abuse/Neglect/Exploitation.

Note: For reporting suspected abuse, neglect or exploitation occurring at UTHCPC, consult the procedure on Reporting and Investigating Abuse/Neglect/Exploitation at UTHCPC.

Staff Training

UTHCPC staff are required to complete 8 hours of Patient Rights training on initiation of employment and every year thereafter. These 8 hours of training include the following:

Assessment criteria for victims

Reporting guidelines

Identification of private and public community agencies that provide help and assistance for victims

Clinical staff assessment

Assessment for abuse and neglect is an ongoing process from admission through discharge. Each of the following clinical staff must note on his/her respective assessment tools that s/he has completed an evaluation for identification of abuse and/or neglect at time of admission to the facility:

Registered nurse

Social service clinician

Physician

Positive findings

If a clinical staff finds positive findings of suspected or alleged abuse/neglect, s/he must do the following:

Triggers the findings to the MPA for consideration on the Master Treatment Plan

Follows the reporting guidelines indicated above

Registered nurse responsibilities

The registered nurse interviews the patient privately to conduct an abuse/neglect assessment of the patient's behavioral and physical findings at present to note criteria that may be suggestive of abuse and/or neglect.

Does the clinician indicate that findings match criteria of abuse?

If yes, the registered nurse completes the direct questioning and triggers a problem statement to the MPA.

If no, the registered nurse does not observe the criteria.

Social services responsibilities

The social service clinician assesses the patient further within the context of the Psychosocial Assessment to determine the following:

The actual history of the suspected abuse/neglect

The family history and onset

Physician responsibilities

The physician assesses further the physical and mental condition of the patient to determine whether the patient can have proper care at UTHCPC or should be transferred to a medical facility (BTGH).

Considering abuse: The physician considers the possibility of abuse/neglect and follows it with history and physical examination in the following situations:

When the patient's explanation of how s/he had an injury does not seem plausible

When a delay in seeking medical care exists

When the patient presents with vague complaints

Reporting abuse or neglect

Health professionals are obligated to report suspicions of abuse or neglect of adults or children to the Texas Department of Protective and Regulatory Services at 1-800-252-5400.

Referral resources

If a patient is identified as a victim of abuse/neglect, the treatment team refers him/her to available resources. UTHCPC maintains the following list of national, state and local resources:

If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.