ABUSE

IN  NURSING  HOMES

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      There are those few people who choose to prey on the helpless.  When staff and family members are less than vigilant, abusive behavior from those who purposefully mistreat a resident may go undetected, especially with a resident who is unable to communicate well.  By being aware and recognizing the many forms of abuse, family members and other visitors can help staff identify and remove from the care environment those who would physically and emotionally harm susceptible residents.



                                                             PAGE CONTENTS

        ∆  The problem of abuse.

        ∆  Definition of abuse.

        ∆  Indicators or symptoms of abuse.

        ∆  Types and examples of abuse.

        ∆  Nursing home abuse prevention systems.

        ∆  Responding to allegations of abuse from

               a family resident.

        ∆  Responding to the potential for immediate harm.

        ∆  Submitting a formal complaint or grievance.

        ∆  Investigation of abuse allegations.

        ∆  Involving oversight authorities.



∆  The problem of abuse.

      The elderly and chronically ill often have a powerless dependance upon others for the basics of life and so become vulnerable to those who prey on nursing home residents through physical, verbal, emotional, sexual, financial, or neglectful abuse.  Their vulnerability can amplify the fear of negative consequences that might come from reporting even minor instances of abuse.  Nursing home residents are easily intimidated and can find it difficult to point out abuse because of their mental and physical dependency or fear of punishment, embarrassment, or other forms of reprisal.


    The potential for elder abuse is not limited to nursing home staff.   Abuse can also result from the actions of other residents, family members, outside medical practitioners, or anyone involved in the affairs of the patient such as attorneys, clergy, family friends, or even professional con artists.


  ∆  Definition of abuse.

   Abuse is willful or grossly neglectful or intentional behavior that results in physical pain; the infliction of physical injury or mental anguish; unreasonable confinement or restraint; or intimidation or punishment by a family member, nursing home employee, other medical care provider, or other nursing home resident.  Abuse results directly or indirectly in physical and/or mental harm, pain, or anguish. Indirect causes of abuse can be misappropriation of funds or property or a failure to provide goods and services necessary to avoid physical harm or mental anguish.


  ∆  Indicators or symptoms of abuse.

   Many of the abuse indicators can also result from other causes.  It is best to seek the assistance of a neutral, knowledgeable outside entity such as the Ombudsman for advice if you are unsure a complaint or investigation for abuse is indicated.


    The following symptoms alone do not always signal abuse.  Many of them, such as depression, are often an outcome of aging, illness, or natural mental and physical changes.

  1. (1)New, unusual behavior such as extraordinary reactions to ordinary stimuli.


  1. (2)Measurable physical signs such as dehydration, malnutrition, broken bones, pain from touch, skin damage, or bruising; injuries of an unknown source; soiled linen or clothing; or changes in personal hygiene.


  1. (3)Behaviors such as depression, change in the amount and method of communication, self isolation or withdrawal, increased anxiety and anger, change of normal activities, or avoiding certain visitors or health care providers.


  1. (4)Indications of an abusive family member or home caregiver can be forced isolation from family, friends, and outside care givers; lack of adequate care; lack of signs of affection for the patient;  complaining of the burden of caring for the patient; conflicting statements about the patient’s care needs, behaviors, or health condition; inappropriate sexual comments about or behaviors toward the patient; or a history of psychological, criminal, or violent behavior in the family of the caregiver.


  1. (5)Financial exploitation can be indicated by missing belongings, suspicious legal signatures, numerous checks made payable to cash, an individual who is unclear about monthly income, bills not paid, tax returns not filed or filled with suspicious data, unusual bank account activity or withdrawals, and uncalled for changes in wills, trusts, or other property documents.


  ∆  Types and examples of abuse.

  1. (1) Physical

-Hitting, slapping, pushing, physical punishment, or rough treatment.

-Purposefully allowing a resident to fall.

-Conducting or allowing inappropriate sexual touching or rape.

-Physical or chemical restraints limiting the resident’s movement for the convenience of staff or others.

-Unattended health complications such as bed sores or pain control for injuries.

-Physical injuries such as scratches, bruises, welts, and skin conditions that would indicate unjustified restraints.

-Significant weight loss and/or lack of response to weight loss.

-Allowing fleas, lice, dried fecal matter, continuing urine odors, roaches, ants, or mice to become established on the resident or in their room.


  1. (2) Verbal

-Yelling, cursing, or threatening.

-Making suggestive sexual remarks.

-Cruel, negative teasing.

-Not responding to attempts by the resident to communicate.

-Speaking to the patient in a short, negative manner.

-Belittling or talking down to the resident.


  1. (3) Chemical

-Withholding, borrowing, or refusal to administer drugs prescribed for the resident.

-Diversion of drugs from the resident’s supply for staff or family member’s use.

-Use of drugs to limit the movements and behaviors of the resident.


  1. (4) Negligence

-Failing to provide needed assistance in activities of daily living or provide food or liquids.

-Failing to carry out the resident’s plan of care in a way that could produce direct or indirect harm.

- Failing to do what the average person with the employee’s training and job duties would or should do to care for the resident under the same circumstances.

-Failing to protect resident from abuse by staff, residents, family members, or others.

-Failing to respond to the resident’s poor personal hygiene or other quality of life issues.


  1. (5) Psychological

-Public belittling or humiliation.

-Gossiping about or spreading confidences related by the resident.

-Isolating the resident against their will or purposefully limiting their contact with others.

-Suggesting or directly threatening the resident with harm, discharge from the facility, deprivation, or embarrassment.


  1. (6) Misappropriation

-Theft of a patient’s money or property or asking a patient to loan money.

-Requiring or implying the need for gifts or money for regular care tasks or special errands for the resident.

-Using a resident’s property as your own such as their telephone or television.

-Encouraging or allowing others to use the residents property without their consent such as borrowing clothing for use by another resident.

- Appropriating or exploiting the resident’s property or funds by abusing legal processes.


  ∆  Nursing home abuse prevention systems.

   Nursing homes must work to anticipate the possibility of abusive employees and situations that may result in abuse of residents.  As Medicare/Medicaid certified care providers, they are required to develop and have, at a minimum, a seven point process in place to prevent, respond to, and report abuse.  The emphasis is on avoiding hiring those who might abuse, responding quickly to accusations of abuse to protect residents, investigating signs or suspicion of abuse, and reporting their findings to appropriate authorities.


   The nursing home must develop and implement policies and procedures that include the seven covered below.  A facility is not restricted to these seven areas, but can and should, in appropriate circumstances, develop policies and procedures beyond these requirements to protect residents. A facility’s policies and procedures should detail how they plan to carry out the those requirements to protect residents from abuse.The requirements are:

  1. (1)Screening: Screen employment applicants for a history of abuse or mistreating residents.  This includes attempting to obtain information from previous employers and/or current employers and checking with appropriate licensing boards and registries.


  1. (2)Training: Train employees through orientation and ongoing sessions on issues related to abuse prohibition and prevention.


  1. (3)Prevention: Provide residents, families, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear or retribution; and respond with appropriate feedback regarding the concerns that have been expressed.  Identify, correct, and/or intervene in situations in which abuse, neglect, or misappropriation of resident property is more likely to occur.


  1. (4)Identification: Identify abuse signs and events such as suspicious bruising of residents; occurrences, patterns, and trends that may constitute abuse; and determine the direction of an appropriate investigation.


  1. (5)Investigation: Investigate incidents, identify staff member(s) implicated in the alleged violation, and report the results to the proper authorities.


  1. (6)Protection: Protect residents from potential harm during an investigation.


  1. (7)Reporting/Response: Have procedures to:

    * Report all alleged violations and substantiated incidents to all agencies and authorities as required, and take all necessary corrective actions depending on the results of the investigation;

    * Report to the State nurse aide registry or licensing authorities knowledge of any actions by a court of law which would indicate an employee is unfit for service; and

    * Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences.


  ∆  Responding to the potential for immediate harm.

If the situation leaves the resident open to some form of harm if not immediately addressed, the concern should be voiced without hesitation to the unit nurse.  The reporting person should behave with the expectation of an immediate response from the nurse, director of nursing, social worker, administrator, or other supervisory person who can provide the necessary action to assure the safety of that resident and any others who may be affected by the situation.  It is best to continue pressing the matter up the staff chain of command until the reporting person is satisfied the resident is out of potential harm’s way and appropriate action has been taken to prevent the situation from reoccurring.


    Some responses by the nursing home to immediate or potential harm could include an immediate transfer of the resident to a hospital or another room, to put a suspected employee on suspension, or to call the police to investigate the suspected abuser.  The facility should do whatever is necessary to protect the resident from potential or continued abuse.


∆  Responding to allegations of abuse from a family resident.

    The family should support the resident in reporting any negative behaviors toward them by others in the nursing home.  Families often express their reluctance to report or file grievances because they didn’t want to complain or decide that what a resident told them really didn’t happen.  No matter the mental or emotional state of the resident, any sign or word of potential abuse should be reported to and investigated by the nursing home without regard to how unreal it may sound.


  ∆  Submitting a formal complaint or grievance.

    A written complaint or grievance should be filed according to the nursing home’s policies and procedures unless the time necessary to go through such a process leaves the resident exposed to potential or actual jeopardy.  Most nursing homes have policies and procedures for filing grievances on forms available in public areas of the facility for anyone’s use.  Don’t hesitate to pursue the results of your complaint if no response is provided within a reasonable time.


     It is important to report a concern as soon as possible after it happens along with the details of the matter.  Nursing home management needs to know the who, what, where, and when of the matter being reported.  If they are to pinpoint the cause of your concern they need to know the staff members involved, specifically what concerns you, where it happened, and what day and time it occurred.  Knowing the when, where, who, and what allows management to pinpoint the staff on duty or others who may be involved.


  ∆  Investigation of abuse allegations.

  The nursing home should investigate all complaints and report those that would qualify as abuse to the appropriate authorities.  Not every grievance or complaint qualifies as abuse. The nursing home must discriminate between quality of care issues and matters that have the potential for abuse when responding to family reports of problems and concerns.  Many do not meet the definition of abuse and treating every grievance as abuse would overload the official investigation processes.


    Allegations of true abuse must be reported to oversight agencies by the facility in accordance with State law.  The State agency may accept the results of the nursing home’s investigation or follow up with their own investigation.


   A few cold meals are a quality of care issue and not usually a threat to the resident’s well-being.  Cold meals should still be appropriately reported to the facility with an expectation of the problem being corrected.  Purposely withholding meals could be abuse in the form of neglect or punishment and should be pursued accordingly as potential abuse.


    If the family member disagrees with the response to their grievance by the nursing home, they can file a complaint with a number of local and state agencies.  Complaints by individuals directly to the State survey and certification agency can result in a formal investigation by that agency.


    During an investigation at the facility by the State survey agency, the nursing home is not given the name of the person filing the complaint nor is the resident involved directly identified.  Although their information requests may indicate a specific individual, the investigators will make an effort to avoid disclosing the identification of the resident who is at the center of the investigation.  The goal is to diminish the fear of the family or resident of retaliation by the nursing home or those accused of practicing abuse.  If there is a finding of substantiated abuse, the identity of the involved resident will have to be indicated.


  ∆  Involving oversight authorities.

    A listing of the names, addresses, and telephone numbers of appropriate oversight agencies and advocacy groups should be posted in a public place in the nursing home and made available to residents and family members upon request.  When a family feels to the need to go to an outside party to address a serious problem such as abuse, these agencies can either direct you to a source of help or investigate and enforce compliance of the care regulation(s) in question.  If you are not sure of which agency is appropriate for your situation, the local LTC Ombudsman’s office may be the best starting point for help and direction to the right agency.




   For more information on the functions of the Ombudsman, go to the page Ombudsman’s Help in the Nursing Home in this website by clicking HERE.


   For more information on regulations §483.13(b) Abuse and §483.13(c) Staff Treatment of Residents in the document Appendix PP click on the link below.

http://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf



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