411-054-0028 Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare (1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local Department office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local Department office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION OF ABUSE OR SUSPECTED ABUSE. In addition to immediately reporting abuse or suspected abuse to the Department, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. (4) IMMUNITY AND PROHIBITION OF RETALIATION. (a) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident’s safety or welfare. The information that is shared may include the reporting of violations of licensing or certification requirements, criminal activity at the facility, violations of state or federal laws or any practice that threatens the health and safety of a resident of the facility to: (A) The Long-Term Care Ombudsman, the Oregon Department of Human Services, a law enforcement agency or other entity with legal or regulatory authority over the facility; or (B) A family member, guardian, friend or other person who is acting on behalf of the resident. (b) Unless performed with the intent to comply with state or federal law, including but not limited to protecting residents’ rights or carrying out a facility’s policies and procedures that are consistent with state and federal law, it is interference with the disclosure of information as described in subsection (a) if a facility: (A) Asks or requires an employee or volunteer to sign a nondisclosure or similar agreement prohibiting the employee or volunteer from disclosing the information; (B) Trains an employee or volunteer not to disclose the information; or (C) Takes actions or communicates to the employee or volunteer that the employee or volunteer may not disclose the information. (c) The facility licensee, employees and agents must not retaliate in any way against anyone who participates in the making of an abuse complaint, including but not limited to restricting otherwise lawful access to the facility or to any resident, or if an employee, dismissal or harassment. (d) Anyone who, in good faith, reports abuse or suspected abuse shall have immunity from any liability that might otherwise be incurred or imposed with respect to the making or content of an abuse complaint. Statutory/Other Authority: ORS 410.070, 443.450 & 443.417 Statutes/Other Implemented: ORS 443.400 - 443.455 & 443.991 History: APD 55-2021, amend filed 12/09/2021, effective 12/15/2021 APD 23-2021, temporary amend filed 06/21/2021, effective 06/23/2021 through 12/19/2021 SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07