CMS SOM App. U, Tag R108

of property.

Interpretive Guidelines: §403.730(c)(3)

Patients must not be subjected to any type of abuse by any individual, including but not

limited to staff, other patients, consultants, volunteers, family members, legal guardians,

friends or other individuals.

“Abuse” means the willful infliction of injury, unreasonable confinement, intimidation,

or punishment with resulting physical harm, pain or mental anguish (see

42 CFR §488.301). This includes staff neglect or indifference to infliction of injury or

intimidation of one patient by another.

Neglect means a failure to provide goods and services necessary to avoid physical harm,

mental anguish, or mental illness. (See 42 CFR §488.301)

Surveyor should keep in mind that this is non-medical model and should not expect to see

medical care given. Patient should receive the care indicated in their care plan.

This also includes the deprivation by an individual, including a caretaker, of goods or

services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all patients, even those in a coma, cause

physical harm, or pain or mental anguish.

“Misappropriation of property” means the deliberate misplacement, exploitation, or

wrongful, temporary or permanent use of a patient's belongings or money without the

patient's consent. (See 42 CFR §488.301)

The facility must have a mechanism in place that is designed to identify potential abuse

situations, investigate allegations, and protect patients and staff during investigations.

Through the quality assessment and performance improvement system and staff training,

the facility must demonstrate ongoing attempts to prevent future incidents of abuse.

Survey Procedures:

If during the course of a survey, surveyors identify potential abuse situations, investigate

allegations through interviews, observations, and record reviews. Report and record any

instances where the survey team observes an abusive incident. Completely document

who committed the alleged abusive act, nature of the abuse, and where and when it

occurred. Ensure that the facility addresses the incident immediately.

• What type of complaints do individuals report (if any) and how well does the

facility respond?

• Are adequate systems in place to protect patients from abuse and

misappropriation of property?

• Are incidents reported appropriately?