Mitigate Your Risk: Responding to Alleged Abuse

A resident reported alleged abuse to his nurse, who immediately notified the supervisor.  What happens next will have a significant impact on your facility. CMS updated the Abuse Critical Element Pathway in October 2022, requiring facilities to update their policy and procedure for alleged abuse. Following a standardized process to complete a thorough investigation is crucial in maintaining compliance with CMS requirements.

Immediate Response

Separate the involved individuals. Identify the victim, perpetrator, and witnesses. Prevent contact between the perpetrator and other residents. Complete an assessment to determine if the victim is injured. Ensure that the victim receives necessary medical treatment. Gather the facts.

Date, time location of alleged assault
Details of alleged abuse
Take statements of victim, perpetrator, and witnesses

Notify the physician and family. Consult psychiatry if needed. Re-evaluate the BIMS, order a 1:1 if indicated, order treatments as needed, and update the care plan. Report to the appropriate outside agencies based on CMS requirements.

Serious bodily injury – immediately but no later than 2 hours 
No bodily injury – within 24 hours 

You are likely familiar with the steps of the immediate response. However, it is crucial to evaluate your process to ensure that your facility follows policy and procedure and executes a consistent, standardized response for every incident of alleged abuse.


The investigation and written report must be completed within 5 business days of the incident.

The facility must outline the actions taken in response to the allegation of abuse. The report must detail the thorough investigation of the alleged abuse. Describe the full scope of the investigation and interviews to support the rationale of the outcome. Outline the steps taken to prevent further potential abuse while the investigation is in progress. Establish an action plan limiting the perpetrator’s access to residents at risk. Corrective actions must be outlined, including the plan for ongoing monitoring. Report the results of all investigations to the administrator or designated representative and to other officials in accordance with State law, including to the State Survey Agency. If the incident is verified as abuse, is appropriate corrective action must be taken.

While the investigation procedure may be familiar to you, it is necessary to ensure that your facility follows a standardized response process for every incident of alleged abuse.

Mitigate Your Risk

Alleged and confirmed abuse puts facilities at risk. Protect your facility by reviewing your policy and procedure to ensure that you are addressing all the CMS requirements. Scrutinize your facility’s response to alleged abuse to ascertain that you have a standardized process in place. Act now to identify and correct areas of vulnerability to help mitigate your facility’s risk when responding to alleged abuse.