Preventing Elder Abuse in Nursing Homes

There are approximately 1.4 million elderly individuals living in long term care facilities, like nursing homes, and their families have high expectations for the quality of their care. While many nursing home residents receive adequate healthcare, a significant number experience neglect and abuse. It is estimated that about one-third of all nursing homes have residents who suffer from abuse by staff or other residents (Masters in Health Care). Defining elder abuse can be challenging due to different definitions. However, the most common forms of abuse found in nursing homes include physical, sexual, emotional or psychological mistreatment, neglect, abandonment, and financial exploitation.

To effectively prevent the mistreatment of elderly individuals, addressing nurse shortages is a simple solution to tackle the issue of nursing home abuse.

Despite appearing to be a new phenomenon, elder abuse in nursing homes has been occurring for many years. The elderly, due to their physical and cognitive vulnerabilities, are unable to defend themselves against the abusive actions of their caregivers.

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While physical aggression is commonly associated with nursing home abuse, psychological abuse is also prevalent. It may be difficult to imagine mistreating a helpless individual, but the problem of elder abuse in nursing homes continues to escalate. According to the American Association for Justice (source), there were 20,673 complaints of abuse, neglect, and exploitation from nursing home and "board and care" residents in 2003. However, by 2010, this number had risen significantly to between one million and two million complaints according to the National Center on Elder Abuse.

A study conducted by the Special Investigations Division of the House Government Reform Committee unveiled that approximately 30% (5,283 facilities) of nursing homes in the United States were cited for nearly 9,000 instances of abuse within a recent two-year period.

The study revealed prevalent problems such as untreated bedsores, inadequate medical care, malnutrition, dehydration, avoidable accidents, and insufficient sanitation and hygiene. These issues encompass multiple forms of elder abuse in nursing homes including physical abuse, sexual abuse, psychological abuse, neglect, abandonment, and financial exploitation.

Physical abuse, as defined by the National Center on Elder Abuse, involves the use of physical force that can cause bodily injury, physical pain, or impairment. This includes various violent acts such as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. It also encompasses other forms of physical abuse like the inappropriate administration of drugs and restraints and force-feeding. Physical punishment is another form of abuse.

According to Brent & Adams research findings cited in an ABC news interview with Helen LoveABC news, approximately sixteen percent of nursing home abuse cases involve physical abuse. Love herself shared her personal experience as a 75-year-old grandmother of three who became a victim of nursing home abuse. She disclosed being choked and suffering from a broken neck during the incident.

He broke my wrist bones, in my hand. He put his hand over my mouth." Two days after the interview, Helen Love died. Nursing home officials did not report her beating to a state official who was at the nursing home at the time. Ultimately, though, Love's attacker served a year in prison.

An investigation revealed that he had been fired by two previous nursing homes for aggressive behavior. A report by the Senate Select Committee on Aging found that many nursing home abuse cases are not immediately reported to law enforcement official (Robinson). According to a recent report from the American Association of Justice, one in fourteen incidents of elder abuse were not reported to the authorities.

Emotional or psychological abuse towards older individuals involves causing anguish, pain, or distress through verbal or nonverbal means. This includes actions such as verbal assaults, insults, threats, intimidation, humiliation, and harassment. Examples of emotional/psychological abuse towards older individuals include treating them like infants, isolating them from loved ones and regular activities, giving them the "silent treatment," and enforcing social isolation (National Center on Elder Abuse). Around twenty percent of reported elder abuse cases involve emotional abuse (Brent & Adams). While emotional abuse is the most prevalent form of abuse among elders, it is also difficult to define due to its subjective nature. Consequently, holding nurses accountable for these offenses becomes challenging. In contrast to emotional abuse's subjectivity, neglect and other serious crimes are objective and comparatively easier to identify.

Neglect is when someone fails to fulfill their obligations or duties towards an elder. This can include a person with fiduciary responsibilities not providing care, or an in-home service provider failing to give necessary care. The National Center on Elder Abuse adds that neglect can also involve not paying for essential home care services. According to Brent & Adams, caretaker neglect accounts for twelve percent of abuse cases.

Neglect, as defined by the National Center on Elder Abuse, is when an elderly person is not given essential necessities like food, water, clothing, shelter, personal hygiene items, medicine, comfort, personal safety and other responsibilities. A case of nursing home neglect occurred in May 2012 involving George Dayln Houser. Houser was found guilty in Atlanta for defrauding Medicare and Medicaid of $32.9 million dollars. He was the owner of three nursing homes in Georgia.

Houser agreed to meet certain obligations in order to receive Medicare and Medicaid payments, such as providing a safe and clean physical environment, nutritional meals, medical care, and other forms of assistance for residents. However, Houser failed to fulfill these obligations by not maintaining sufficient nursing staff and failing to pay suppliers for various services including food, pharmacy services, clinical laboratory services, medical waste disposal, trash disposal, and nursing supplies. The FBI has documented these failures (FBI).

In addition to neglecting their responsibilities, caregivers also pose a significant threat through physical abuse. Not only do they subject residents to neglectful actions but they also exploit them financially and materially.

The National Center on Elder Abuse defines financial or material exploitation as the illegal or improper use of an older person's funds, property, or assets. This includes actions such as cashing an elderly individual's checks without permission, forging their signature, stealing their money or possessions, deceiving them into signing documents, and misusing conservatorship, guardianship, or power of attorney.

In 2009, a nursing home worker in Chicago was charged with financial exploitation and aggravated identification theft for allegedly stealing $4,008 from an Illinois nursing home. The individual was fired from their job and awaited trial while out on bail. It was revealed that they had a prior conviction for forgery.

Insufficient staffing in nursing homes is directly associated with different types of abuse. A recent study conducted by the American Association for Justice revealed that 90% of nursing homes in the United States do not have enough staff to provide adequate care. Nursing home residents who live in facilities with staffing levels below the minimum standards are at a higher risk of developing bedsores and experiencing significant weight loss compared to those residing in better-staffed homes. This is because there needs to be sufficient staff available to assist residents who cannot eat independently, and elderly individuals who are immobile require regular repositioning to prevent bedsores. Moreover, understaffing contributes to low employee morale and frustration, which hinders their ability to interact patiently and respectfully with residents.

The American Association for Justice states that many nursing homes do not meet the recommended staffing levels set by federal officials (3.45 nursing hours per patient daily) and nursing home experts (4.55 nursing hours per patient). Insufficient hours per patient can result in various problems in nursing care, with neglect being the most concerning issue.

Continuous nursing care in nursing homes is highly sought after to prevent medical issues like pressure ulcers and blood clots. In New York, cases of elder abuse resulting from inadequate care have led to liability, causing injuries or even deaths among residents. Insufficient staffing has been identified as a contributing factor to these instances of abuse. Given that insufficient staffing is unquestionably the primary cause of nursing home abuse, what impact does the projected shortage of nurses have on this problem?

The American Association of Colleges of Nursing predicts that the nursing shortage in the United States will worsen due to the aging population and increased healthcare demands. According to a Health Affairs article from July/August 2009, Dr. Peter Buerhaus and his colleagues found that although there was temporary relief during the recession, it is expected that by 2025, there will be a shortage of 260,000 registered nurses. This would be the largest deficit since the mid-1960s. The article "The Recent Surge In Nurse Employment: Causes And Implications" attributes this projected shortage primarily to an aging workforce.

Currently, nurses sometimes have to handle 20 patients simultaneously, which is considered towards the lower end of the nurse-patient range. According to federal law, nursing homes certified by Medicare and Medicaid must appoint a registered nurse (RN) as their director of nursing (DON). They are also required to have an RN available for at least 8 hours per day, 7 days a week, and a licensed nurse (either an RN or LPN) on duty for the remaining time. However, there are no specific minimum staffing levels mandated for nurse's aides who primarily provide daily care. Instead, nursing homes must ensure they "provide sufficient staff and services" in order to guarantee the overall well-being of each resident both physically and mentally. If a nursing home only meets these federal requirements for nurse staffing, each resident would receive approximately 20 minutes of nurse time per day.

(Source: Elder Law Answers)

In 2000, the Centers for Medicare and Medicaid Services (CMS) advised that nursing home residents should have at least three hours of staff time each day. This includes two hours from nursing assistants and one hour from licensed nurses. The CMS also indicated that the optimal staffing level is three hours from nursing assistants and one hour from licensed nurses (Elder Law Answers).

According to a study conducted by Charlene Harrington, a professor at UCSF School of Nursing, it is suggested that improving staffing levels in nursing homes can be achieved by increasing state standards. The study shows that nursing homes in states with the highest staff level standards have sufficient staff to prevent safety violations. Therefore, raising the minimum staffing ratio set by each state directly affects the quality of care provided to nursing home residents. Effective enforcement of these mandates on nursing homes is necessary due to the significant impact of both state and federal standards on the quality of care.

According to an article published by nursing home reality, Aaron Delurey endorses three procedures to ensure residents receive adequate care: First, each state should mandate an increase in surprise inspections outside of regular business hours on weekdays. Second, management personnel should always work staggered shifts, not only when state officials are present in the building. What is the reason behind requiring this change?

When management is absent, the quality of care provided tends to decline. A crucial measure to ensure proper staffing levels is for state inspectors to promptly examine payroll data, covering the 14 consecutive days leading up to their visit, during inspections. Additionally, inspectors should enforce a rule that prevents any further staffing reinforcements while they are present at the facility. Ultimately, these procedures would help alleviate the nursing shortage and reduce misconduct in nursing homes.