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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Caregiver Misconduct Investigations and Reporting
Policy Number: 4.47
Effective Date: October 1, 2016
Chapter: Legal Services
To establish a process for receiving, investigating, and, if required, reporting, allegations of Caregiver
Misconduct and injuries of unknown source as required by the Wisconsin Caregiver Law.
II. POLICY ELEMENTS
UW Health will comply with all legal requirements related to alleged incidents of Caregiver Misconduct
and injuries of unknown source.
A. Caregiver Misconduct means Abuse, Neglect, or Misappropriation of Property as defined below.
Some actions by caregivers, while not appropriate, are not considered Caregiver
Misconduct. Examples of such actions include complaints that "my nurse wasn't nice to me," "he
was not very professional," or "it took her thirty minutes to give me pain medications." When in
doubt about whether a complaint constitutes Caregiver Misconduct, you must treat it as potential
Caregiver Misconduct and follow the procedures listed below in section IV.
B. Abuse means:
1. An act or repeated acts by a caregiver, including but not limited to restraint, isolation or
confinement, that, when contrary to UW Health's policies and procedures, is not part of
the patient's treatment plan and is done intentionally to cause harm and does cause any of
a. Causes or could reasonably be expected to cause pain or injury to the patient or
the death of the patient, and the act does not constitute self-defense under
b. Substantially disregards a patient's rights under Wisconsin Statutes Chapters 50
or 51 (e.g., mental health, AODA, developmentally disabled) or a caregiver’s
duties and obligations to a patient.
c. Causes or could reasonably be expected to cause mental or emotional damage to
a patient, including harm to the patient's psychological or intellectual functioning
that is exhibited by anxiety, depression, withdrawal, regression, outward
aggressive behavior, agitation, or fear of harm or death, or a combination of these
behaviors. This section does not apply to permissible use and application of
restraints, isolation, or confinement.
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2. An act or acts of sexual contact (inappropriate touching) or intercourse under Wis. Stat.
§ 940.225 by a caregiver.
3. The forcible administration of medication or the performance of psychosurgery,
electroconvulsive therapy, or experimental research on a patient with the knowledge that
no lawful authority exists for the administration or performance.
4. A course of conduct or repeated acts by a caregiver which serve no legitimate purpose
and which, when done with intent to harass, intimidate, humiliate, threaten, or frighten a
patient, causes or could reasonably be expected to cause the patient to be harassed,
intimidated, humiliated, threatened, or frightened.
5. Examples of Abuse may include, but are not limited to:
a. Hitting, slapping, pinching, kicking, or otherwise intentionally causing a patient
b. Inappropriate sexual contact;
c. Words or acts that threaten to harm or intentionally frighten a patient;
d. Actions that humiliate, harass, or intimidate a patient (e.g., making lewd
comments about a patient's body, threats of punishment or depriving care or
possessions, etc.); and
e. Intentionally taking a patient's call light away.
6. Abuse does not include an act or acts of mere insufficiency, unsatisfactory conduct, or
failure in good performance as the result of inability, incapacity, inadvertency, or
ordinary negligence in isolated instances, or good faith errors in judgment or discretion.
C. Neglect means an intentional omission or intentional course of conduct by a caregiver, including
but not limited to, restraint, isolation, or confinement that is contrary to UW Health's policies and
procedures, is not part of the patient's treatment plan, and through substantial carelessness or
negligence, does any of the following:
1. Causes or could reasonably be expected to cause pain, injury, or death to the patient.
2. Substantially disregards a patient's rights under Wisconsin Statutes Chapters 50 or 51
(e.g., mental health, AODA, developmentally disabled) or a caregiver’s duties and
obligations to a patient.
3. Causes or could reasonably be expected to cause mental or emotional damage to a
patient, including harm to the patient's psychological or intellectual functioning that is
exhibited by anxiety, depression, withdrawal, regression, outward aggressive behavior,
agitation, or fear of harm or death, or a combination of these behaviors.
NOTE* Neglect does not include use and application of restraints permitted by policy
and applicable law.
4. Examples of Neglect include:
a. Intentionally withholding care, medications, food, etc.
b. Failure to follow a plan of care that could reasonably be expected to cause pain,
injury, or death of a patient.
c. Neglect does not include an act or acts of mere inefficiency, unsatisfactory
conduct or failure in good performance as the result of inability, incapacity,
inadvertence, or ordinary negligence in isolated instances, or good faith errors in
judgment or discretion.
D. Misappropriation of Property means:
1. The intentional taking, carrying away, using, transferring, concealing, or retaining
possession of a patient's movable property without the patient's consent and the intent to
deprive the patient of possession of the property.
2. Obtaining property of patient by intentionally deceiving the patient with a false
representation, which is known to be false, made with the intent to defraud, and which
does defraud the person to whom it is made. “False representation” includes a promise
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made with the intent not to perform it if the promise is a part of a false and fraudulent
3. By virtue of his or her position, the employee has possession or custody of a patient’s
money or other items of value, and intentionally uses, transfers, or conceals the money or
items of value without the patient's consent, and with the intent to make the money or
property his or her own or to the use of another person except the owner.
4. Intentionally using or attempting to use personal identifying information, as defined in
Wis. Stat. § 943.201(1)(b), to obtain credit, money, goods, services, or anything else of
value without the authorization or consent of the patient and by representing that he or
she is the patient or is acting with the authorization or consent of the patient.
5. Examples of Misappropriation of Property include, but are not limited to:
a. Theft of money, identity, credit cards, clothing, electronics, medication or
b. Misuse of property such as using a patient's cell phone without consent.
E. An injury should be classified as an injury of unknown source when both of the following
conditions are met:
1. The source of the injury was not observed by any person or the source of the injury could
not be explained by the patient.
2. The injury is suspicious because of the extent of the injury or the location of the injury
(e.g., the injury is located in an area not generally vulnerable to trauma) or the number of
injuries observed at one particular point in time or the incidence of injuries over time.
A. Staff Training and Patient Information.
1. UW Health staff will be trained on these procedures in New Employee Orientation
(NEO) sessions and in other settings as appropriate.
2. Patients will be informed of their rights related to potential incidents of Caregiver
Misconduct via the "Patient Rights and Responsibilities," which is provided at the time of
B. Source of Allegations of Caregiver Misconduct.
UW Health staff may become aware of potential cases of Caregiver Misconduct or an injury of
unknown source by one or more of the following:
1. Personally observing the incident or observing unexplained injuries
2. Hearing of an incident from other staff
3. Verbal or written assertions by the patient
4. Patient Safety Net Report
5. UW Health Compliance Hotline
C. Initial Actions When Learning of Alleged Incidents of Caregiver Misconduct.
Whenever any UW Health staff member becomes aware of an alleged incident that may meet the
definition of Caregiver Misconduct, they are required to do the following:
1. Report allegations of Caregiver Misconduct to supervisor:
a. Alleged incidents of Abuse and/or Neglect.
i. All staff are required to immediately report any suspected incidents of
Abuse and/or Neglect to their supervisor or their supervisor's designee. If
the incident occurs after hours or on the weekend/holiday, the nursing
supervisor shall be notified.
ii. The supervisor or designee is required to report the incident to their
Director and to Corporate Counsel (608-261-0025) within 24 hours of
learning of the alleged incident to ensure that the incident is documented
and an investigation is appropriately conducted.
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b. Alleged Misappropriation of Property.
Missing patient belongings including money and other personal property may be
viewed as Caregiver Misconduct under certain circumstances. Therefore, staff is
required to notify the Corporate Counsel (608-261-0025) of any allegations of
stolen money or property within 24 hours of learning of the alleged incident.
Please see Administrative Patient Care Policy 7.27-Management of Patient
Belongings for more information.
2. Take measures to protect the patient from further harm. As soon as possible upon
learning of the alleged incident of Caregiver Misconduct, steps must be taken to protect
the patient from possible subsequent incidents of misconduct or injury. Responsive
measures may include, but are not limited to, removing the alleged caregiver from
providing the patient's care, moving the patient to another clinical area, addressing and
treating evidence of physical or emotional harm, and removing the suspected caregiver
D. Investigating and Documenting Alleged Incidents of Abuse and Neglect.
1. Time Frame for Completing and Reporting Investigation to Corporate Counsel. To the
extent Corporate Counsel requests UW Health staff assistance with an investigation
involving alleged incidents of Caregiver Misconduct, the UW Health staff member is
expected to complete and provided documentation of his or her investigation to the
Corporate Counsel within 3 days to mail code 8360 or fax 608-203-1016. The Corporate
Counsel will maintain documentation related to all Caregiver Misconduct investigations.
2. Investigating the Allegation. The nature and scope of the investigation will be at the
discretion of Corporate Counsel with assistance from Human Resources, Patient
Relations, Risk Management, and or other departments or individuals as needed.
Investigations involving UW-Madison faculty physicians or other employees will be
coordinated with UW School of Medicine and Public Health Human Resources and
others, as appropriate. The supervisor or his or her designee may be asked by Corporate
Counsel to assist in the investigation, in which case the supervisor or his or her designee
shall immediately initiate investigative steps, which may include the following acts:
a. Collecting and preserving any physical and documentary evidence including
collecting photographs, copies of medical records, and other documents.
b. Conducting interviews of the victim(s) and potential witness(es), including the
person(s) with whom the allegation is made against.
c. Collecting other corroborating/disproving evidence.
d. After consultation with Corporate Counsel, notifying the UW Police Department
in a situation where there is a potential criminal offense.
3. Content and documentation of the investigation. When conducting an investigation the
following questions should be answered and/or summarized:
1. Who was present at the time and place of the incident?
2. Was there anyone else in the vicinity of the incident that might have knowledge
of the incident?
3. Who saw, heard, or overheard what transpired?
4. What exactly happened and how did it happen (from the perspective of the victim
and the alleged caregiver)?
5. What effect did it have on the patient?
6. When did the incident occur?
7. Where did the incident occur?
8. What are the actions taken as a result of this?
E. Determining Whether a Report to a Governing Regulatory Body Must be Made.
UW Health's Corporate Counsel or designee is responsible for determining when an alleged
incident of Caregiver Misconduct must be reported to the Wisconsin Department of Health
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Services, Division of Quality Assurance (DQA), or other regulatory agencies as appropriate. Any
reports to DQA will be based on criteria established in regulations and guidance published by the
Division of Quality Assurance. As necessary, Corporate Counsel will consult with appropriate
personnel (generally the supervisor(s) involved, employee, Human Resources, Risk Management,
Patient Relations, and/or relevant senior leadership) in order to make such a determination.
F. Documenting Release of Medical Information. Reported Caregiver Misconduct incidents must be
documented using UW Health's "Accounting of Disclosure" form. See Administrative Policy
6.23-Accounting of Protected Health Information Disclosures.
G. Informing Accused Caregiver of Submitted Report. UW Health will inform, via letter, any staff
reported to the Division of Quality Assurance for an alleged incident of Caregiver Misconduct.
H. Corrective Action
1. Caregiver Misconduct is Abuse, Neglect, or Misappropriation of Property a serious work
rule violation and will not be tolerated. If UW Health determines that the employee
committed Abuse, Neglect, or Misappropriation of Property, the employee may be
discharged for a first offense.
2. GME trainees or medical staff alleged to have engaged in Caregiver Misconduct may be
subject to corrective action in accordance with the Medical Staff Bylaws or the GME
trainee Appointment Information Document.
I. Non-Retaliation Policy. No employee will be retaliated against for reporting or participating in an
investigation related to Caregiver Misconduct. Employees shall report concerns about retaliation
to either their department or the Human Resources (HR) department. Departments receiving such
allegations shall report them to HR. HR shall determine who will investigate the matter.
Departments shall consult with HR before closing such investigation.
V. FORMS AND REFERENCES
Misconduct Definitions, Wisconsin Department of Health Services / Division of Quality Assurance (P-
The Wisconsin Caregiver Program Manual for Entities Regulated by the Division of Quality Assurance
Caregiver Misconduct Reporting Requirements Worksheet (DQA form F-00161 (12/2014))
Flowchart of Entity Investigation and Reporting Requirements (DQA form F-00161A (12/2014))
Caregiver Misconduct Incident Report form (DQA form F-62447 (04/2010))
Patient Rights and Responsibilities (PR-42949-15)
Administrative (Non-Clinical) Policy 6.23-Accounting of Protected Health Information Disclosures
Administrative Patient Care Policy 7.27-Management of Patient's Belongings
Wis. Stat. § 146.40(4r)(am)
Wis. Admin. Code ch. DHS 13
Sr. Management Sponsor: Chief Legal Officer & General Counsel
Author: Corporate Counsel
Approval Committee: UW Health Administrative Policy & Procedure Committee
UW Health Chief Administrative Officer
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Next revision: 102019