How to address the issue of resident abuse in senior living

by Jim Burke

When news broke earlier this year that a young woman, an incapacitated resident of a long-term care facility in Arizona, had given birth after allegedly being raped by her nurse, it was only the latest in a litany of abuse cases that seem to plague the long-term care industry, including senior living. At Senate hearings in March, for example, one woman testified how her elderly mother, a woman with Alzheimer’s who lived in a Minnesota memory care community, similarly had been abused by a nursing assistant.

But it’s not just sexual abuse of residents that is an issue. Here are just a few examples of other issues:

• A South Carolina-based operator of state-owned veterans’ homes is being investigated for allegations of neglect and substandard care, including failure to respond to resident-on-resident physical violence.
• Earlier this year, employees of a Columbus, OH, facility were charged with involuntary manslaughter after one resident of the home where they worked allegedly died as a direct result of their neglect (with wounds that turned gangrenous) and another suffered serious harm.
• A Jacksonville, FL-area based chain of nursing homes was sued for a stunning $350 million – an amount overturned by a judge in January – for allegedly both withholding therapy and treatments to residents as well as providing them when not needed. In one instance, a hospice resident, seeking end-of-life comfort and pain relief, allegedly was put through strenuous occupational and physical therapy. In others, residents with diabetes reportedly went without regular blood sugar tests for more than a month.

Abuse of residents of senior living communities and skilled nursing facilities is not the norm, of course, but it is a persistent and pervasive problem. Hearings such as the Senate’s one earlier this year, and others at the state level, emphasize the role of public policy and regulations in identifying and stemming abuse of residents and improving care quality.

The expectation is that once standards of care are set, employers will make every effort to attract, vet and retain staff that meets them. Meeting that expectation can be a challenge, however.

If abuse of residents is a persistent problem, then it also is an underreported one, making completely accurate data somewhat problematic. Most incidents are categorized as elder abuse, because six out of seven residents are aged 65 or more years. The majority of those who are especially at risk have dementia or moderate cognitive impairment. With communication skills and judgment impaired, they are unable to report abuse, so it continues without consequence.

In terms of the types of abuse inflicted, rape may be the most shocking type, but it’s not the most common. According to the National Center on Elder Abuse, the most common types are physical (29%) and psychological (21%) abuse, followed by gross neglect and financial exploitation (both 14%) and sexual abuse (7%). And it is not always staff members who are to blame: resident-to-resident abuse is an issue, too, representing 22% of incidents.

Fixing the problem requires approaching it from a variety of different directions. For starters, we need to raise awareness of the issue, and everyone – from family members to caregiver teams and managers – should know the signs of abuse and / or neglect. The most significant red flags:

• Physical abuse: Inadequately explained bruises, skin tears, multiple fractures or long-bone fractures.
• Sexual abuse: Bruising of the breasts, chest or genital areas; an unexplained sexually transmitted disease; bloody or purulent discharge; and undergarments that are unusually stained.
• Physical and / or medical abuse or neglect: Unintended weight loss, poor hygiene, dehydration, social withdrawal, suspicious wounds, unmonitored medications and poorly managed medical conditions.

Better, though, is to establish environments where abuse is not allowed to flourish. Not only is that the right thing to do, the stakes have gone up for facilities accepting federal dollars but failing to create safe havens with the F600 series of tags that the Centers for Medicare & Medicaid Services introduced to its survey process. The F600 tags address adherence to operating practices that are free from abuse, neglect and exploitation. They put responsibility squarely on the facility, reinforcing the importance of having an abuse policy and procedures in place that are well-communicated and strictly followed.

Regardless of where a community is located or whether a community accepts Medicare or Medicaid funding, however, several best practices are key to preventing abuse:

• Screening: Before employees or volunteers are allowed to work with residents, reference, certification and licensing verification and criminal background checks should be mandatory. Any individual found guilty of abuse, neglect or exploitation or with a disciplinary action against his or her professional license for those reasons should not be hired. Training on the abuse policy should be mandatory for new employees and volunteers before contact with residents, and so should be an all-hands attendance at periodic in-service on the policy.
• Training: A comprehensive and ongoing education program covering aspects of resident abuse, neglect and mistreatment should be mandatory for staff and volunteers. Among the topics: Ways to identify residents who are at risk, how to recognize signs of mistreatment, how to report abuse without fear of reprisal, and understanding the Resident Bill of Rights. Staff should be trained to handle and respond appropriately to difficult resident behaviors, and to recognize caregiver signs of burnout, frustration and stress.
• Prevention: The policy on prevention should cover a range of procedures, starting with a resident assessment before move-in and a regular vulnerability assessment thereafter. Other procedures should consider the community’s physical environment, population and provisions related to the risk of admitting predatory offenders, all of which are contingent on specific state and statutory requirements.
• Reporting and response:Again, specific state law and statutory requirements apply, but a two-hour window is recommended if allegations involve abuse or result in serious bodily injury. If abuse is not alleged and serious bodily injury is not involved, it should be reported within 24 hours. Reporting is made to the community’s executive director and state authorities (its survey agency, adult protective services) and law enforcement.

Communities that sharpen their focus on policies, procedures and ongoing training will create an environment where resident abuse is an unlikely risk. Ultimately, however, we need to do more, and stronger public / private partnerships may make the biggest difference in improving the care and safety of some of our society’s most vulnerable members.

David Gifford, M.D., MPH, of the American Health Care Association / National Center for Assisted Living may have put it best after testifying at the March Senate hearing: “We should expand federal programs that attract healthcare workers to the nursing home profession. We should strengthen federal regulations around reporting and sharing of information about employees who have engaged in abuse through the creation of a national background check registry. And we should make resident and family satisfaction ratings of nursing homes publicly available.

Although Gifford cited nursing homes in particular, similar actions — attracting high-quality workers, improving the reporting and sharing of information about employees who have engaged in abuse, and sharing satisfaction ratings, where available — would help senior living communities as well.

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How to address the issue of resident abuse in senior living