Elder Abuse in Residential Care Facilities
Elder abuse is a catch all term referring to any deliberate or negligent act by a care giver or any other individual that results in harm or a major risk of harm to a vulnerable adult over the age of 60 years (Stefanacci & Haimowitz, 2013, p. 68). Under the umbrella definition for elder abuse, more specific types of abuse can be identified such physical abuse, sexual abuse, emotional abuse, exploitation, neglect and abandonment (Stefanacci & Haimowitz, 2013, p. 68).
The physical abuse refers to the infliction, or threat to inflict, physical harm onto an elderly individual or the deprivation of their basic needs. Sexual abuse is defined as any form of nonconsensual sexual contact. Exploitation refers to the illegal misuse, theft, or concealment of an elderly individual’s funds, assets, or property. Neglect is the failure or refusal of a formal or informal caregiver to supply the vulnerable elder in their care with shelter, food, health care, or protection. Abandonment refers to the desertion of the vulnerable elder by either a legal custodian or anyone who has assumed responsibility for their care (Stefanacci & Haimowitz, 2013, p. 68).
Residential care facilities (RCFs) have a multitude of different names across the Unites States but are most commonly referred to as assisted living facilities (ALFs), adult congregate living facilities, domiciliary care homes, and shelter care homes. Since the mid 1990’s, RCFs have made up one of the most rapidly expanding areas of senior housing, with an estimated number of 1 million senior residents living in RCFs across the United States (Castle & Beach, 2011, p. 248). Of concern is the fact that many of the residents in RCFs suffer from some degree of cognitive impairment, physical limitation, or behavioral symptomology that makes then more vulnerable victims of elder abuse (Castle & Beach, 2011, p. 249).
As mandatory reporters of abuse and neglect, it is vital that nurses are trained to identify and assess the presence of abuse or neglect among their patient populations. The nurse must also be aware of state and federal laws that concern the reporting of elder abuse when it is identified. The aim of this paper is to present statistical data showing the under reporting of elder abuse in RCF, highlight deficiencies in staff training that contribute to the problem and discuss the impact of elder abuse on the health care system and nursing.
The Issues Involved with Elder Abuse in Residential Care Facilities
Nurses have a moral obligation to uphold the principles of beneficence, maleficence, and fidelity when caring for patients in any health care setting. The principle of beneficence refers to the expectation that the nurse will do good to prevent harm, while nonmaleficence refers to the nurse’s obligation to protect the patient from harm. The principle of fidelity relates to the nurse’s obligation to not abandon the patient and maintain continuity of care (Westrick & Dempski, 2009, p. 258).
According to the ANA Code of Ethics for Nurses with Interpretive Statements (2001), “the nurse promotes, advocates for and strives to protect the health, safety and rights of the patient” (pg. 16). When the nurse identifies factors within a healthcare delivery system that endanger the welfare and wellbeing of the patient action must be taken to report the problem to a higher authority either within the institution or to an appropriate external authority (American Nurses Association, 2001, p. 19).
Five areas of concern have been identified in relation to assisted living facilities. The first is that ALFs were initially modeled to serve the elderly population who required minimal assistance. However, the population in these facilities has increasingly grown to resemble that of a nursing home in regard to cognitive and physical problems. Physical and cognitive impairment are frequently cited as significant risk factors associated with elder abuse (Phillips & Guo, 2011, p. 344). A second issue concerning ALFs is that in a majority of states, the facilities are mainly staffed by unlicensed assistive personnel (UAP) who often have less education than a certified nursing assistant (CNA). A vital element in the prevention of elder abuse and neglect is staff education regarding problem management and conflict resolution (Phillips & Guo, 2011, p. 344).
A third major concern is that unlike nursing homes, ALFs are not subject to federal regulation. The uniform monitoring and regulation of nursing homes by the federal government is thought to be a key deterrent to the mistreatment of their residents (Phillips & Guo, 2011, p. 344). Fourth, small ALFs that house less than 50 residents are isolated and all but invisible, leaving their residents vulnerable to abuse (Phillips & Guo, 2011, p. 344). Fifth, the fact that most ALFs operate for profit has been named as risk factor for elder abuse and neglect (Phillips & Guo, 2011, p. 344). Because assisted living facilities are regulated at the state level, no federal mandate exists for their inspection and there are no mechanisms in place for complaint investigation. In contrast to ALF, nursing homes have a consistent inspection schedule and the inspection process is governed by the Online Survey Certification and Reporting System (OSCAR). Over the last few years, licensure agency directors with Association of Health Facility Survey Agencies (AHFSA) have voiced concern that current regulations are no longer adequate to meet the needs of the residents that now residing in RCFs (Hawes, 2010, p. xi).
Impact on Patient Health Care
The characteristics of individuals living in RCFs make residents vulnerable to mistreatment. This vulnerability can result from the elder patients’ dependency on a caregiver secondary to chronic illness or cognitive impairment. In 1999, a national survey showed that 32% of RCF residents required help with four activities of daily living (ADLs), and 75% required help with at least three ADLs (Gibbs & Mosqueda, 2004, p. 31).
Surveys of RCFs have revealed that abuse is common. According to Gibbs and Mosqueda (2004), a study of one particular facility revealed that in a 12 month period 36% of the staff admitted to witnessing an episode of abuse and 81% admitted to witnessing episodes of psychological abuse (pg. 31).
Multiple research studies have linked elder mistreatment with increased morbidity and mortality rates. Victims of elder abuse experience more frequent hospitalization for reasons associated with injury, malnutrition, pressure sores, and depression (Baker, 2007, p. 314). Researchers have also linked stress, most likely a result from continuous threats to safety, as a contributor to early mortality among the elderly (Baker, 2007, p. 314).
Residents of RCFs often experience continued victimization because of a failure to report abuse. Residents and families cited the reasons for this as believing that reporting was useless, fear that the staff would retaliate, and wish to find a resolution by working with the facility (Gibbs & Mosqueda, 2004, p. 31). According to the Government Accounting Office (GAO), fear of retribution and lack of information about reporting procedures were the most commonly cited reasons by residents and families for failure to report (Gibbs & Mosqueda, 2004, p. 32).
Because state regulation is so variable, evidence suggests that some facilities do not operate at a high quality of care level (Castle & Beach, 2011, p. 251). Inadequate staff training and staffing levels are major contributors to the problem of elder abuse in the RCFs (Castle & Beach, 2011; Hawes, 2010). RCFs were not initially modeled as a substitute for nursing homes, but rather as a more cost effective, less prohibitive living situation for the medically stable older adult (Phillips & Ziminski, 2012, p. 500)
Based on the initial design, one would assume that neglect would not be serious issue in ALFs because the residents would be able to attend to their own health care needs and protect themselves from harm. However, in the changing market of healthcare, seniors and their families now view the ALF as a viable alternative to nursing home placement. Also, many residents of ALFs deemed medically stable when they moved in have “aged in place” and are now experiencing increasingly unstable health. Finally, although ALFs may be marketed to seniors as upscale facilities, in reality the residents are isolated. This isolation makes the resident uniquely vulnerable to abuse and neglect because they become reluctant to complain or are unaware that their needs are not being sufficiently met (Phillips & Ziminski, 2012, p. 500).
The under-reporting of abuse and neglect within RCFs has been identified as a major widespread issue. Ombudsmen have reported that care facilities often take the position that an abuse claim cannot be proven if it has not been witnessed, therefore claims from residents are often discounted or disregarded (Hawes, 2010, p. xii). The increasing prevalence of residents with cognitive impairment also contributes to this issue. Research has shown that nearly 40% of residents in RCFs have some degree of cognitive impairment making the supervising staff at these facilities less likely to accept the report of abuse as being reality based (Hawes, 2010, p. 9).
Challenges to Nursing and Approaches to Decrease Prevalence
In 2004, the population of elders aged 65 years and older in the United States was estimated to number 36.3 million, by 2030 this number is predicted to increase to approximately 71.5 million (Baker, 2007, p. 313). According to Baker (2007), if current prevalence appraisals remain true, 2.3 million elders will be experience some form elder mistreatment by 2030 (pg. 313).
Recognition and assessment of elder abuse is a vital component of nursing clinical practice. However, studies have revealed that nurses continue to be grossly unaware of the numerous forms of abuse that occur and the appropriate course of action to take when abuse is suspected (Falk, Baigis, & Kopac, 2012). Additionally, public health nurses are now in the position of acting as surveyor in the State Health Department, the regulating body responsible for licensing ALFs (Phillips & Ziminski, 2012, p. 499).
The findings of recent studies have brought attention to the issue of abuse and neglect in ALFs and highlight the increasing vulnerability of residents in these care areas. The assumption the all ALFs are “upscale” and that “out of pocket” payment guarantees good quality or safe care have been challenged (Phillips & Ziminski, 2012, p. 506). The American Medical Association (AMA) recommends that clinicians screen for elder abuse in all clinical areas. Furthermore, according to the Medicare Program, nursing facilities are obligated to screen and monitor their residents for those signs and symptoms linked with elder abuse (Falk et al., 2012).
It is vital that nurses act as advocates by being knowable about state law, reporting mechanisms, and social support groups. It is imperative the nurses’ work with state legislators as well as community and advocacy groups such as the National Association of Assisted Living Nurses and the National Center for Assisted living to reinforce enforcement actions and advance laws (Phillips & Ziminski, 2012, p. 506).
The nurse’s role as educator to our patients is also called into play. As nurses we are able to take on the responsibility of educating our patients, as health care consumers, about the pros and cons of RCFs. It is also important that we educate our patients on recognizing and reporting all forms of abuse (Phillips & Ziminski, 2012, p. 506). In the same regard, the nurse is responsible for providing unlicensed assistive personnel (UAP) and certified nursing assistants (CNA) with the training required to utilize screening and assessment tools. Because residents in ALFs have more autonomy, it is especially important that all staff be trained in the recognition of self-neglect (Falk et al., 2012).
Finally these findings and the lack of current research on the prevalence of elder abuse in ALFs reinforce the need for nurses to become actively involved in research to assist in the identification of potential public health problems. Also, additional research in this field will help to build up national databases to evaluate all areas of public health and assist in the development of “best-practices” (Phillips & Ziminski, 2012, p. 507). Conclusion
Although research regarding the prevalence of elder abuse and neglect in assisted living facilities is lacking, reports from staff and ombudsmen have revealed that it is a widespread and significant issued being faced. Lack of federal regulation and inconsistent state regulation has contributed to the high prevalence of elder abuse in assisted living facilities. By taking a more active role in legislation and through consistent screening and reporting the nurse can influence laws regarding regulation of these facilities.
References
American Nurses Association (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursesbooks.
Baker, M. W. (2007). Elder mistreatment: risk, vulnerability, and early mortality. Journal of the American Psychiatric Nurses Association, 12(6), 313-321. http://dx.doi.org/10.1177/1078390306297519
Castle, N., & Beach, S. (2011). Elder abuse in assisted living. Journal of Applied Gerontology, 32(2), 248-267. http://dx.doi.org/10.1177/0733464811418094
Falk, N. L., Baigis, J., & Kopac, C. (2012). Elder mistreatment and the elder justice act. Online Journal of Issue in Nursing, 17(3). http://dx.doi.org/10.3912/OJIN.Voll7No03PPT01
Gibbs, L. M., & Mosqueda, L. (2004). Confronting elder mistreatment in long-term care. Annals of Long-Term Care, 12(4), 30-34.
Hawes, C. (2010). Detecting, addressing and preventing elder abuse in residential care facilities. Retrieved from http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf
Phillips, L. R., & Guo, G. (2011). Mistreatment in assisted living facilities: complaints, substantiations, and risk factors. The Gerontologist, 51(3), 343-353. http://dx.doi.org/10.1093/geront/gnq122
Phillips, L. R., & Ziminski, C. (2012). The public health nursing role in elder neglect in assisted living facilities. Public Health Nursing, 29(6), 499-509. http://dx.doi.org/10.1111/j.1525-1446.2012.01029.x
Stefanacci, R. G., & Haimowitz, D. (2013). What we need to report and to whom... Geriatric Nursing, 34(1), 68-71. http://dx.doi.org/10.1016/j.gerinurse.2012.12.006
Westrick, S. J., & Dempski, K. (2009). Essentials of nursing law and ethics. Sudbury, MA: Jones