MOMIJI HEALTH CARE SOCIETY
Developer:
PSC

Category:
Health & Safety

Domain:Effective Date:
October 2020

Subject Title:
Zero Tolerance of Abuse

Approval:
Executive Director

Last Reviewed:
October 2020

Next Review:
September 2023

Pages:
7Supersedes:
NEW

Policy #:PURPOSEThis policy has been established to1.
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Prevent abuse from happening at Momiji Health Care Society (MHCS) be it againstclient, staff, volunteer or others;
Define abuse and neglect;Express the duty to make mandatory reports of alleged and confirmed incidents of abuseor neglect; andDescribe the steps involved in investigating a reported incident of abuse
Outline the consequences for anyone involved in an incident of client abuse
To ensure appropriate action is taken following a report of abuse

POLICYAll clients shall be treated with respect and dignity, protected from abuse and neglect by staff,
service providers, volunteers, students and others associated with MHCS.
MHCS has Zero Tolerance for abuse. All allegations of client abuse will be handled in aconfidential manner and shall be carefully investigated and addressed.
MHCS shall make every effort to ensure that there are no repercussions for the reporting party.
All MHCS constituents are legally, morally and ethically obligated to report any incidents ofabuse they witness.
MHCS will accept and act upon anonymous reports. However, complainants should understandthat Management’s ability to take meaningful and effective follow-up action, or any action at all,may be unduly compromised when the source of complaint could not be followed up with.
Zero Tolerance within this policy means that MHCS shall:Uphold rights of everyone to be treated with dignity and respect on MHCS premises andto be free from abuse and neglect
Not allow the abuse of any client by staff or volunteers, nor condone the abuse of any
person by any other at MHCS
Treat every allegation of abuse as a serious matter and investigate

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Take corrective action, including sanctions or penalties against perpetrators of abuse.
Report to the relevant authority every suspected or confirmed incident of abuse
Make every effort to eliminate abuse through staff education, quality improvement,client/resident safety and risk management measures
Develop and post a Clients’ Bill of Rights, this Zero Tolerance of Abuse Policy and aWhistle Blowing Protection Policy
Provide information and education regarding abuse and its prevention as a part oforientation for new staff and volunteers
Ensure clients and substitute decision makers are informed upon admission of MHCS’s
Zero tolerance of Abuse policy and their duty to report abuse

SCOPE
This policy applies to all residents/clients, staff, families, volunteers, students and other service
providers.
PROCEDURESA.

ABUSE EDUCATION AND PREVENTION
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Ensure all clients, their families and substitute decision-makers are aware of:
The Zero Tolerance of Abuse PolicyThe expectation that the policy will be complied with at all times
The actions that clients or their SDM should take in the event that anincident of abuse takes place
Conduct Criminal Record Check on all prospective employees and volunteers
who are likely to work with vulnerable individuals prior to their being accepted
into the Centre.
Post the abuse policy in areas easily accessible to the public.
Include a statement about the abuse policy in the Senior Residence tenants’handbook and highlight the policy to all tenants and/or their SDMs uponadmission.
Annually provide a reminder to tenants about the abuse policy.
Annually review with and educate staff about zero tolerance for abuse andneglect, mandatory reporting requirement, whistleblowing protection.

WHEN ABUSE IS SUSPECTED
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Any staff, volunteer or student who witnesses, or suspects alleged abuse orneglect will intervene to ensure client/staff safety and well-being.

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Any other person who has first knowledge of abuse or suspected abuse areencouraged to inform a member of MHCS staff.

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A MHCS staff who is advised of or who has first knowledge of abuse orsuspected abuse shall immediately inform their supervisor who will immediately
ensure the wellbeing of the victim and help accessing help.
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C.

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The Executive Director and Director of Care will be immediately notified of any
allegation/incident of abuse/neglect.

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The Executive Director will notify the Board Chair of all suspected/alleged
abuse/neglect.

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The victim of abuse will be assessed by the nurse on site for injury and help
access further medical examination if needed.

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The Director of Care will secure and ensure the integrity of the evidence at thesite, take pictures of the site, or any injury suffered by the victim.

8.

Disclosure of information related to incidence of abuse will be made inaccordance with the guidelines of the “Municipal Freedom of Information andProtection of Privacy Act”, and the “Personal Health Information Protection Act”
by the Executive Director, the Director of Care or a duly appointed delegate.

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In the situation where there are reasonable grounds to believe that the substitutedecision-maker/family is responsible for the alleged, suspected or witnessed
incident of abuse or neglect, the Executive Director/Director of Care is not
required to speak to them of the incident or the result of the investigation.

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The Executive Director will provide notification of all allegations of abuse to therelevant authority e.g. the police.

INVESTIGATION OF SUSPECTED OR WITNESSED ABUSE/NEGLECT
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Investigation of any allegation of abuse/or neglect shall be conducted incompliance with the Quality of Care Information Protection Act (QCIPA).
An investigation shall be initiated immediately for any allegation of abuse and/orneglect.
An investigation shall also commence in response to any alleged abusive action
conducted by a family member, visitor or any other individual.
Where the abuse or suspected abuse or neglect is alleged to have been the resultof an employee’s action, an internal investigation shall be initiated with theExecutive Director, or his/her designate, with support from Human Resources
personnel. Meetings will be set with the implicated employees(s), witnesses andall other employees and individuals who may have knowledge of the incident
under investigation.
The employees(s) in question shall immediately be placed on a Leave of Absencefrom active duty with pay at the discretion of the Executive Director and uponfurther investigation with the possibility of discipline or dismissal to follow.
Volunteer(s) suspected of abuse will not be permitted to carry out volunteer
activities pending further investigation with the possibility of termination ofassociation with MHCS to follow.
Individuals external to MHCS (i.e. family members, visitors, etc.) suspected ofabuse shall not be permitted to access MHCS premises pending furtherinvestigation with the possibility of barring of further attendance at MHCS.
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D.

The Executive Director shall complete the investigation of any reported abuse
within ten (10) days of becoming aware of the alleged, suspected or witnessed
incident, or at an earlier date if required by the relevant authority.
The Executive Director shall notify the police after reviewing and ensuring that
pertinent information exists that supports an allegation of abuse, determined to beintentional in nature, by an employee, volunteer, family members, visitor or any
other individual external to the centre.
The Executive Director or designate shall ensure that the victim is permitted tocommunicate in private with independent advocates.
Where applicable, the Director of Care will report the confirmed incident to thestaff member’s professional regulatory bodies.
Capable clients who intended to or conducted an abusive action will be advisedby the Executive Director or designate that their behavior is inappropriate,
unacceptable and subject to reporting to law enforcement authorities.
Referral to support resources will be made available to all parties involved in thealleged abuse. Resources for clients include: His/her and/or family member’s minister or faith group leader, as appropriate
 The client’s and/or family member’s physician
 Any appropriate external health care professional The Advocacy Centre for Seniors
The staff person involved will be referred to the Employee Assistance Program
The Executive Director shall ensure all appropriate incident related
documentations including but not limited to electronic and handwritten
investigation notes, records of analysis of incidents, internal meeting records, andinterview notes with staff are centrally stored with access granted to senior leadersof the organization i.e. Executive Director, Director Care and Director of Finance& Human Resources only. No handwritten or electronic notes are to be left toindividual possession.

FACTORS TO CONSIDER WHEN DETERMINING ACTIONa.

Mitigating Factors
 Degree of harm
 Provocation
 Admission of guilt Remorse
 Existing abuse policy
 Previous training
 Momentary flare-up (recurrent history/isolated incident)
 Intention or wilfulness to harm by abuse Employment/service record (length of employment/performance issues)
 Consistency of discipline (previous discipline) Awareness of personal/emotional issues of abuser

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E.

Aggravating Factors
 Use of weapon Potential for serious harm
 Number of blows
 Similar past behavior
 Denial of action

ACTION TO BE TAKEN FOR CONFIRMED ABUSE
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Staff
 Disciplinary action up to and including dismissal.
 Counselling of the staff through Employee Assistance Program Referral to the police for further investigation and possible criminal charges
being laid Barring of the individual from MHCS

2.

Volunteer
 Sanctions up to and including barring of the individual from MHCS
 Referral to the police for further investigation and possible criminal charges
being laid
 Referral to community support services, if necessary Barring of the individual from MHCS

3.

Student
 Sanctions up to and including dismissal from placement at MHCS
 Referral to the police for further investigation and possible criminal charges
being laid
 Referral to the educational institution involved for appropriate follow-up
action Barring of the individual from MHCS

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Contracted Service Provider
 Sanctions up to and including dismissal
 Informing the employer of the service provider
 Referral to the police for further investigation and possible criminal charges
being laid Barring of the individual from MHCS

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Family Member/Visitor
 Counselling with the social worker
 Sanctions up to and including barring of the individual from MHCS
 Referral to the police for further investigation and possible criminal charges
being laid Barring of the individual from MHCS
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Capable Client Referral to the police for further investigation and possible criminal charges
being laid
 Sanctions up to and including barring of the individual from MHCS

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Appendix***********************
DEFINITIONS
Abuse of a client Means any action or inaction, misuse of power and/or betrayal of trust or respect by a person
against a resident, that the person knew or ought to have known, would cause (or could
reasonably be expected to cause) harm to the client’s health, safety or well-being; and Includes, but is not limited to: physical abuse, sexual abuse and sexual assault, emotional
abuse, verbal abuse, financial abuse.
Physical Abuse means the use of physical force by anyone other than a client that causes
physical injury or pain to a client;Sexual Abuse means any consensual or non-consensual touching, behaviour or remarks of asexual nature or sexual exploitation that is directed towards a client by a staff member by aperson other than a staff member;
Emotional Abuse means any threatening, insulting, intimidating or humiliating gestures,
actions, behaviour or remarks, including imposed social isolation, shunning, ignoring, lack of
acknowledgement or infantilization that are performed by anyone other than a client where theperson performing the gestures, actions, behaviour or remarks understands and appreciates theirconsequences;
Verbal Abuse means any form of verbal communication of a threatening or intimidating natureor any form of verbal communication of a belittling or degrading nature which diminishes aclient’s sense of well-being, dignity or self-worth, that is made by anyone who understands andappreciates its consequences;
Financial Abuse means any misappropriation or misuse of a client’s money or property.
Neglect means the failure to provide a client with the care, services or assistance required forhealth, safety or well-being, and include inaction or a pattern of inaction that jeopardizes thehealth, safety or well-being of one or more clients.
Substitute Decision-Maker (SDM), in relation to a client, means the person who is authorized
by law to make decisions concerning the client’s property, and/or personal care, if the client isincapable of making the decision
Consent in this policy refers to: the consent of a client who is capable of making the decision, or
the consent of the client’s legally authorized substituted decision-maker (SDM), if the resident isincapable of making the decision.

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