There was obvious shock and outrage when a 29-year-old resident of an Arizona long-term care facility gave birth after having been incapacitated since the age of three. None of the facility’s staff had any idea she was pregnant.
A licensed practical nurse, one of her caregivers and an employee for nearly 7 years, was charged with rape on the strength of DNA matching with the baby. The aftermath was marked by mass resignations and heightened oversight by the state[.
The tragic incident has provided yet another example of a persistent and troubling issue plaguing the long-term care community: The high rate of violence carried out against residents.
It’s difficult to get completely accurate data on the extent of the problem due to underreporting. While those in all ages and circumstances may be victimized, most incidents that occur in long-term care facilities are categorized as elder abuse as six out of seven residents are 65 or over. Half suffer from an Alzheimer’s-type dementia, while another 25% have moderate cognitive impairment[. With memory failure and communication skills and judgment impaired, dementia patients are especially at risk. They’re unable to report it, so it continues without consequence.
According to National Center on Elder Abuse, the most common are physical (29%) and psychological (21%) abuse, followed by gross neglect and financial exploitation (both 14%), and sexual abuse (7%). And it’s not always staff that’s to blame: resident-to-resident abuse is an issue, too, comprising 22% of incidents.
Watching for signs that long-term care residents are being abused and/or neglected is the first step to remediating the problem. The most significant red flags include:
- 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.
Heading off the risk is the real challenge, though. The human cost aside, the stakes have gone up for facilities participating in Medicare or Medicaid (or both), given the F600 series of tags, citing deficiencies, that the Centers for Medicare & Medicaid Services (CMS) introduced to its survey process. The F-600 tags address their 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.
A facility’s abuse policy should include the following recommended best practices to reduce risks:
- Screening – This should be conducted before employees or volunteers work with residents and covers reference, certification and licensing verification and a criminal background check. No individual found guilty of abuse, neglect or exploitation or with a disciplinary action against his or her professional license for those reasons should be hired. New employees and volunteers are trained on the abuse policy before contact with residents; attendance at a yearly in-service on the policy is mandatory.
- Training – A comprehensive education program covering aspects of resident abuse, neglect and mistreatment should be mandatory for staff and volunteers at orientation and in ongoing sessions thereafter. Topics should include ways to identify residents who are at risk and to recognize signs of resident mistreatment, how to report abuse without fear of reprisal and understanding the Resident Bill of Rights. Training on challenging resident behaviors and ways to intervene is key, along with recognizing caregiver signs of burnout, frustration and stress.
- Prevention – The facility’s policy on prevention of elder abuse covers a range of procedures, starting with a resident assessment prior to admission and a regular vulnerability assessment thereafter. Other procedures should consider the facility’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 facility’s administrator and state authorities (its survey agency, adult protective services) and law enforcement.
The risk of a resident being abused, mistreated or neglected is not the kind of black mark any long-term facility wants to have against it. It goes a long way toward mitigating the risk when management and staff are on top of the issue and guard against it with a comprehensive policy and consistent training over time.
Jim Burke is Vice President at Hub International.
