Abuse of Patients/Clients
Sector: Chronic Care, Complex Continuing Care, Mental Health, Rehabilitation
Patient/client abuse claims include allegations of physical and/or sexual assault, verbal and written threats, financial abuse, and harassment of patients/clients by other patients/clients, staff, volunteers, visitors or healthcare practitioners. Abuse can have lasting physical and psychological effects. In defending these claims, being able to demonstrate the healthcare organization met all relevant standards and implemented reporting policies and preventive practices are critical.
Common Claim Themes
- Physical and/or sexual assault by other patients/clients, healthcare providers and support staff on patients/clients.
- Failure to adequately monitor a patient/client at risk of harming others.
- Physical and/or sexual assault by mental health patients on other patients.
- Failure to adhere to proper restraint policies and practices (including restraint prevention strategies).
- Police involvement.
- Lack of police checks (including child and sexual abuse registries) for staff, credentialed practitioners and volunteers working with patients/clients.
- Failure to follow up or intervene on complaints, allegations, or reports of “suspicious” behavior and document same.
- Family upset with how incident handled.
Case Study 1
While receiving care at a rehabilitation facility, a patient with a history of mental illness and increasing confusion was found attempting to feed fecal matter to another patient. Due to concerns related to potential infectious disease transmission, the other patient was subsequently transferred to tertiary care, where he was later diagnosed with and treated for aspiration pneumonia. Expert review of the case was critical of the care provided by the involved healthcare providers. While the primary nurse assigned to the patient had expressed concerns related to the patient’s inappropriate behaviour prior to the incident, there was no documentation in the patient’s chart to indicate the patient had engaged in behaviours that posed a threat to other patients. Furthermore, it was revealed that despite a documented history of failing to comply with scheduled medication administration and ongoing cognitive deterioration, the healthcare team continued to place the patient in a shared room when their concerns warranted a single room.
Case Study 2
After seeking voluntary treatment for suicidal ideation, a patient was admitted to a psychiatric hospital. On the fourth night of her admission, the patient was assaulted by another patient, who attempted to climb into bed with her while she slept. The patient experienced flashbacks, nightmares and difficulty sleeping in the aftermath of the assault. Expert review of the case was critical of the care provided to the patient, noting that prior to the assault, the assailant had a documented history of sexually inappropriate behaviour. Furthermore, during the shift prior to the assault, the assailant was witnessed acting in a sexually inappropriate manner towards unit nursing staff. Experts were critical of the involved healthcare team’s failure to enact necessary safeguards (i.e. initiate more frequent monitoring, re-locate the assailant closer to the nursing station, implement security personnel) in response to the assailant’s concerning behaviour.
- HIROC claims files.
- Accreditation Canada. (2016). Required organizational practices handbook 2017.
- Canadian Medical Protective Association. (2012). The aging patient – responding to changing demographics.
- College of Nurses of Ontario. (2012). Abuse prevention: One is one too many.
- College of Nurses of Ontario. (2013). Therapeutic nurse-patient relationship. Practice Standard.
- College of Physicians and Surgeons of Ontario. (2008). Guidebook for managing disruptive physician behaviour.
- College of Respiratory Therapists of Ontario. (2014). Abuse awareness and prevention: Professional practice guideline.
- ECRI Institute. (2016). Criminal background checks. Healthcare Risk Control.
- ECRI Institute. (2013). Patient violence. Healthcare Risk Control Risk Analysis (4), Mental Health (2).
- ECRI Institute. (2008). Preventing resident abuse and neglect. Continuing Care Risk Management Risk Analysis (1), Patient/Resident Care (1).
- ECRI Institute. (2013). Resident aggression and violence. Continuing Care Risk Management (2), Safety and Environmental (12).
- ECRI Institute. (2011). Violence in healthcare facilities. Healthcare Risk Control Risk Analysis (2), Safety and Security (3).
- Gallant D J, Herber A P, Roderique H J. (2011). Background checks and references –
- The do’s and don’ts [PowerPoint]. Fasken Martineau Institute Labour, Employment and Human Rights Group Seminar.
- The Joint Commission. (2010). Preventing violence in the health care setting. Sentinel Event Alert (45).
- Long-Term Care Task Force on Resident Care and Safety. (2012). An action plan to address abuse and neglect in longterm care homes.
- Registered Nurses’ Association of Ontario. (2014). Preventing and addressing abuse and neglect of older adults: Person-centred, collaborative, system-wide approaches.
- Webb G. (2013). The prevention of abuse and neglect in Ontario long-term care homes.
Note: The Mitigation Strategies are general risk management strategies, not a mandatory checklist.
Reliable Care Processes
- Adopt an organization-wide abuse and violence prevention program policy and procedures that includes:
- A zero tolerance approach towards patient/ client abuse (including prohibiting non-therapeutic relationships with patients/clients) while promoting a culture of respect and cultural competency;
- A process for confidential/without reprisal reporting of incidents of actual, potential or suspected patient/ client abuse;
- Mandatory external reporting of patient/client abuse;
- Timely investigation and management of all (including unsubstantiated or potential) allegations of patient/ client abuse; document same.
- Ensure staff are aware of the definition for patient/client abuse (i.e. physical abuse, sexual abuse, violence, threats, non-therapeutic relationships, intimidations, financial abuse, harassment and cyber abuse) and the healthcare organization’s abuse policy.
- Ensure the capabilities of healthcare providers and the organization meet the needs of patients/clients, e.g. providers are able to manage patient acuity.
- Ensure appropriate mechanisms are in place for team communication around high risk patients/clients.
- Ensure health and safety management system proactive safety measures are in place (workplace safety inspections, risk assessments).
- Ensure background police (i.e. vulnerable person’s check) and regulatory college checks for all persons who will come in contact with patients/clients).
- Consider requiring a background police check for all existing staff and volunteers (including credentialed practitioners) who have not had a previous background check.
- Ensure all persons who will come in contact with patients/ clients are aware of boundary issues and potential signs of abusive situations including: spending extra time with one patient/client beyond his/her therapeutic needs with little documentation of interactions; changing patient/client assignments to provide preferential care to one patient/client; kissing/hugging patients/ clients; expressions of romantic interest in a patient/ clients; accepting gifts from patients/clients; changes in a patient’s/client’s comfort levels with a particular staff member or another patient/client.
- Require staff education in non-violent crisis intervention/ therapeutic management of disruptive and assaultive behaviour for staff working with at risk populations and/ or higher risk programs (e.g. older adults with challenging behaviours).
- Ensure healthcare providers are aware of how to activate the Code White response for violent persons.
- Consider requiring all staff, locums and volunteers to sign off on the organization’s abuse of patient/code of conduct policy annually.
- Determine whether patient/client consent is required to notify the police of an abuse.
- For confirmed incidents of abuse by staff or volunteers, ensure appropriate progressive discipline, documentation within personnel files, and reporting to regulatory bodies and authorities as required by law.
- Report healthcare providers to the appropriate regulatory body if standards related to effectively establishing and maintaining limits or boundaries in the therapeutic relationship with patients/clients have not been met.
Patient/Client and Family-Centred Care
- Take complaints of abuse seriously and explain the process of investigation all allegations of patient/client abuse.
- Ensure complete and timely documentation of formal care plans or violence risk assessments for patients/clients exhibiting or with a known history of physical or sexual abuse, aggressive and/or combative behaviours (e.g. monitoring, de-escalation strategies).
- Adopt standardized terminology for assessing, communicating and documenting observation/supervision levels of potentially abusive patients/clients (‘close’, ‘constant’, ‘continuous’, ‘routine’, ‘level 1’, etc.).
Monitoring and Measurement
- Implement formal strategies to help ensure consistent adherence to abuse and violence prevention policies/ practices (e.g. periodic chart/e-record audits, analysis of reported incident/events, Code White reports, patient/client relations files, learning from medico-legal matters).