Elder Mistreatment Abuse, Neglect, and Exploitation in an Aging America (2003) / Chapter Skim
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14. Elder Abuse in Residential Long-Term Care Settings: What Is Known and What Information Is Needed?
14. Elder Abuse in Residential Long-Term Care Settings: What Is Known and What Information Is Needed?
Pages 446-500
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From page 446... ...
House of Representatives, 1990~. Although attention has increased somewhat in recent years, most research on elder abuse and neglect has focused on incidence, causes, and risk factors in the community.
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From page 447... ...
. nursing facility operator for their food, medicine, medical care, dental care, and a bed; a roof over their heads; for assistance with virtually every daily activity." On any given day, approximately 1.6 million people live in approximately 17,000 licensed nursing homes, and another estimated 900,000 to 1 million live in an estimated 45,000 residential care facilities, variously known as personal care homes, adult congregate living facilities, domiciliary care homes, adult care homes, homes for the aged, and assisted living facilities (Strahan, 1997; Hawes, et al., 1999, 1995a)
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From page 448... ...
In nursing homes, other types of actions have been included, such as improper use of physical or chemical restraints. Physical abuse also typically includes sexual abuse or nonconsensual sexual involvement of any kind, from rape to unwanted touching or indecent exposure.2 There is somewhat less agreement about whether verbal or psychosocial abuse should be included in the general category of abuse when applied to older persons.
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CNAs who participated in focus groups also had very clear and specific ideas about what constituted neglect in nursing homes (Hawes et al., 2001~. They mentioned a number of examples: .
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(B) ~.3 EVIDENCE ABOUT THE NATURE AND PREVALENCE OF ABUSE AND NEGLECT IN NURSING HOMES For decades, nursing homes have been plagued with reports suggesting widespread and serious maltreatment of residents, including abuse, neglect, and theft of personal property (Douglass et al., 1980; Fontana, 1978; Institute of Medicine, 1986; Mendelson, 1974; Moss and Halamandaris, 1977; New York State Moreland Act Commission, 1975, 1976; Ohio General Assembly Nursing Home Commission, 1978; Stannard, 1973; U.S.
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From page 451... ...
Such conditions were major factors in the passage of the nursing home reforms contained in the Omnibus Budget Reconciliation Act (OBRA) of 1987 (OBRA, 1987~.4 The OBRA 1987 reforms, the most sweeping set of legislative changes to the way nursing homes were regulated since the passage of Medicaid and Medicare, addressed multiple areas of resident care and quality of life.
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. anc impairment In cognitive functioning are common among t" be vast majority of nursing home residents, and clifficult or challenging behaviors are not uncommon, as clisplayeci in Table 14-1.
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The authors reported, "Almost all those approached agreed to be interviewed." Those who declined cited fear of retaliation. Finally, the ombudsmen used CMS Survey protocols to identify "interviewable" residents in long-term care facilities (Atlanta Long-Term Care Ombudsman Program, 2000)
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A 1987 survey of 577 nursing home staff members from 31 facilities found that more than one-third (36 percent) had witnessed at least one incident of physical abuse during the preceding 12 months (Pillemer and Moore, 1989~.6 As displayed in Table 14-2, such incidents included excessive use of physical restraints (21 percent)
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For example, North Shore Elder Services in Danvers, Massachusetts, conducted a recent project on reducing abuse and neglect in nursing homes (MacDonald, 20001. In this project, 77 CNAs from 31 nursing facilities received training.
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The ombudsman program was established in the early 1970s to "identify, investigate, and resolve individual and systems level complaints" that affect residents in nursing homes and residential care facilities (Huber et al., 2001:1~. Federal funds for the program are through the Older Americans Act, and some programs also receive state funding (Huber et al., 1996~.
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, using standardized definitions of complaint types and resolutions (Administration on Aging, 1998~. The 1998 compilation of complaints received by the state Long-Term Care Ombudsman program and its parent agency, the Administration on Aging, using the NORS system, found that, nationwide, physical abuse was one of the five most frequent complaints to ombudsmen about nursing homes (Administration on Aging, 2000~.
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Second, as also discussed later, even when abuse allegations are substantiated, there is rarely a deficiency citation against the facility that would be recorded as an "F-Tag." Third, in most states the agencies responsible for investigating abuse and neglect in nursing homes acknowledge their depen
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nursing homes" (U.S. House of Representatives, 2001~.
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· The cases involving abuse included physical and sexual abuse as well as verbal abuse involving threats and humiliation. Reports from the Nurse Aide Registries One potential source of data on abuse in nursing homes is the nurse aide registries.
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As clisplayeci in Table 14-3, there was tremendous variation in the rate of reported complaints across the states. The reported number of complaints or allegations of abuse, neglect, and misappropriation that were logged into the nurse aide registry system varied from 1 per 1,000 nursing home beds to 174 per 1,000 beds across the states that reported these statistics.
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From page 462... ...
Sadly, there is considerable evidence of the "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness" in the nation's nursing homes. 1lIn this state with a model program, a much higher proportion of complaints addressed issues related to neglect (e.g., 56 percent were about abuse in this state, versus a national average of 70 percent; 38 percent were about neglect)
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From page 463... ...
Ombudsman Reports The 1998 compilation of complaints received by the state Long-Term Care Ombudsman program reported that 27 percent of the complaints ombudsmen received had to do with the types of inadequate care that are typically thought of as neglect (e.g., improper handling, accidents, neglected personal hygiene, and unheeded requests for assistance) (Administration on Aging, 2000~.
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found that many facilities were so understaffed that even though trays were taken into rooms, residents were not fed. EVIDENCE ABOUT THE NATURE AND PREVALENCE OF ABUSE AND NEGLECT IN RESIDENTIAL CARE FACILITIES There are no federal standards that govern residential care facilities, which are known by more than 30 different names across the country.l3 13Those names include personal care homes, adult care homes, adult congregate living facilities, residential care homes for the elderly, shelter care homes, homes for the aged, domiciliary care homes, board and care homes, and assisted living facilities.
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~ ~ .... Other than nursing homes, the most common form of residential settings with services for people with disabilities are generically known as board and care homes, or residential care facilities (RCFs)
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First, RCFs house a population with chronic disease and significant disabilities, as shown in Table 14-4 (Fralich et al., 1997; Hawes et al., 1995a, l995b, l995c, 20001. In particular, residents exhibit relatively high levels of cognitive impairment or another mental health condition, with the exception of residents in relatively high-level assisted living facilities (Phillips et al., 20001.
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Many ot these have been iclentifieci as risk factors for abuse or neglect in other settings. Although estimates vary across states and types of residential care facilities, an estimated one-thirci of residents are poortheir care paid for by a combination of Supplemental Security Income (SSI)
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However, the ombudsman presence in residential care facilities is much more limited than in nursing homes (Phillips et al., 1994~. For example, ombudsmen handled 121,686 cases in FY 1998, but 82 percent of those cases were in nursing home settings; only 17 percent were residents in residential care facilities.
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LIMITATIONS OF ESTIMATES OF PREVALENCE OF ABUSE AND NEGLECT IN LONG-TERM CARE SETTINGS The results of these studies suggest that abuse and neglect are widespread across residential long-term care settings. However, there is no i5This was a national probability sample of residents in Alms that, relative to the general population of places calling themselves "assisted living," provided either high services or high privacy.
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For residents in nursing homes and residential care facilities, those agencies differ across states but typically include ombudsmen, adult protective services, the state survey agency responsible for licensing nursing homes, the state agency responsible for the operation of the nurse aide registry, Medicaid fraud units in the attorney general's office, and professional licensing boards, such as the Board of Nursing or Boards of Nursing Home Administrators. As a result, the data from one agency, such as the ombudsmen, should not be taken as an indicator of the amount of abuse, because "many abuse complaints are reported to other state agencies, not to the ombudsman program" (Administration on Aging, 2000~.
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From page 471... ...
. ~ Widespread Underreporting As noted earlier, reporting of suspected cases of elder abuse is required in most states under mandatory elder abuse reporting laws; moreover, it is required in all states if it occurs in nursing homes under the provisions governing the Nurse Aide Registry (Hawes et al., 2001; Morris, 1998; Steigel, 1995~.
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However, there is some evidence that physicians rarely or never report suspected cases of elder abuse involving nursing home residents (U.S. Department of Health and Human Services, OIG,1990b)
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Underreporting by Residents and Family Members There is also evidence from surveys and focus group interviews of underreporting by residents and family members (Atlanta Long-Term Care Ombudsman Program, 2000; Bowers et al., 2001; Hawes et al., 2001; Pettee, 1997~. In focus group interviews, surveys, and individual interviews, some residents and family members expressed a general reluctance to complain, evidently feeling that there were other mechanisms for resolving problems, such as working through the resident and family councils or speaking with the administrator.
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From page 474... ...
Only 39 percent of the state nurse aide registry directors felt that facilities reported allegations of abuse or neglect "all of the time" (Hawes et al., 2001~. Second, it was clear that differing concepts of the nature of abuse led some respondents to label reports of verbal or psychological abuse as overreporting, as illustrated by the following quote from on agency's director/program manager.
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There are several reasons for such low substantiation rates. First, in some states considerable time elapsed between the time the alleged incident occurred and the formal investigation by the state nurse aide registry.
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As a result of these factors, the actual number of abuse and neglect cases reported by the nurse aide registries as substantiated is quite small relative to the number of allegations received. In focus group interviews, the directors of the state survey agencies that had overall administrative authority for the nurse aide registries expressed concern about the relatively low rates of substantiation, particularly because most tended to believe that residents and families complained only when something significant had occurred.
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This section discusses issues related to research on prevalence of abuse and neglect in long-term care settings. First, we discuss nursing homes and then residential care facilities, if there are different issues.
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In general, there are two types of residential care facilities. One group includes facilities specifically licensed for special populations, such as for persons with substance abuse, mental illness, or developmental disabilities.
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In nursing homes, the majority of residents receive assistance in three or more ADLs, so a random sample would produce adequate numbers of residents with significant physical impairment. Most residents also have moderate to severe cognitive impairment.
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Sampling decisions in residential care are complicated by the fact that there appears to be significant variation across states. Some, like North Carolina, have made aggressive use of RCFs to limit use of nursing homes.
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Most experts agree that in-person interviews are most likely to produce valid and complete information about such sensitive information as their experiences in nursing homes or RCFs. In interviews with residents about whether they had ever had complaints about the care they received and how they handled it, Barbara Bowers and I had great difficulty getting residents to discuss this difficult topic.
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Most residents in nursing homes and RCFs (except assisted living facilities) have a roommate.
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of any grantees who are selected to study abuse and neglect in nursing homes. In their attempts to protect subjects, some IRBs place such severe restrictions on researchers that meaningful and important research cannot be accomplished.
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Indeed, nearly all the responses, including the role of low wages, emphasized the role of staffing shortages and poor staff to resident ratios as major causes of abuse and neglect in nursing homes (Hawes et al., 2001~. This was consistent with prior studies.
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Staff Training and Aggressive Residents Staff in many of the state aide registry agencies believed that inadequate training for CNAs was a major factor causing or contributing to abuse and neglect. In part, they suggested, some CNAs might lack an understanding of what constituted abuse.
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From page 486... ...
In part, they believed the residents' aggressive behaviors were intentional, that is, that the resident was aware of what he or she was doing. This belief often persisted even when the examples given by the CNAs indicated that the residents had some level of cognitive impairment.
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Implications for Research Topics The following are a few suggestions about the types of research topics that might generate better estimates of prevalence and inform efforts to prevent abuse and neglect in nursing homes and residential care facilities.
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· Do any EDs have protocols in place for identifying suspected cases of abuse and neglect among residents of nursing homes and residential care facilities, for documenting adequately to differentiate between accidental trauma and abuse or neglect, and for reporting such cases to appropriate authorities? Are these protocols followed?
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, the Atlanta Long-Term Care Ombudsman program, and the North Shore Legal Services Program. · An examination of the effects of different types of training for nursing facility and RCF staff, resident and family education and empowerment interventions provided by ombudsmen programs (effects on both detection and reporting as well as on prevention)
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· Examine the effect of environmental factors (e.g., that make work in nursing homes more or less difficult or burdensome for staff) and more or less confusing (or in the case of bathrooms, unfamiliar and disturbing)
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Fairfax, VA: Price Waterhouse for ALFA. Atlanta Long-Term Care Ombudsman Program 2000 The Silenced Voice Speaks Out: A Study of Abuse and Neglect of Nursing Home Residents.
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Becker 1992 Nurse's aides in nursing homes: The relationship between organization and quality. The Gerontologist 32(3)
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Testimony before the U.S. Senate Special Committee on Aging-Forum on the Risk of Malnutrition in Nursing Homes.
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Shanley 2001 Preventing Abuse and Neglect in Nursing Homes: The Role of the Nurse Aide Registries. Report to the Centers for Medicare and Medicaid Services (formerly HCFA)
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Kramer 1998 Quality of Care Problems Persist in Nursing Homes Despite Improvements since the Nursing Home Reform Act. Paper prepared for the Committee on Quality on Long-Term Care, Institute of Medicine.
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Archives of Internal Medicine 156:449-453. 1997 Risk factors for reported elder abuse and neglect: A nine-year observational cohort study.
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Bachman-Prehn 1991 Helping and hurting: Predictors of maltreatment of patients in nursing homes. Research on Aging 13:74-95.
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Kane, and M Finch 1995 Effects on physical functioning of care in adult foster homes and nursing homes.
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Government Printing Office. 1997 State of Maryland's Ombudsman Program for Processing of Elder Abuse and Neglect Complaints and Accuracy of Geriatric Nurse Aide Registry.
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Ziemba, and P McGovern 1993 Elder abuse in long-term care environments: A pilot study using information from long-term care ombudsmen reports in one California County.
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