Financial Abuse

Financial Abuse—This is the intentional use of another person’s financial assets without legal authorization. Nursing home residents may not be aware they’re being taken advantage of or have the mental capacity to approve changes in their financial accounts, deeds and wills.

The expansive definition of this act is when someone illegally uses a nursing home resident’s property, money, or assets. This can involve someone stealing personal belongings from the elder or obtaining identifying information and misusing the elder’s credit or debit cards. It could even extend to having the patient draw up a new will or authorizing a disbursement of funds from their bank accounts when they did not understand what the transaction really was about.

It also includes fraudulently executing a new power of attorney or signing over a deed. A number of these acts require actions from a coherent mind and if the elder is not truly cognizant, the actions would be illegal.

Any type of fraud is a criminal act and should be reported to local law enforcement authorities. See the “What You Should Do” tab for additional information.

Source: Centers for Disease Control

Emotional Abuse

emotional abuseAny behavior that harms a resident’s emotional health, contentment, or their self-worth could be considered emotional abuse. Actions that fall under this category include giving a patient the “silent treatment,” isolating them from their relatives and friends, causing distress or pain through verbal or non-verbal actions, or treating them like a child. It could also include threats, humiliation, harassment, or intimidation.

These actions may not even be intentional. They could be the result of the caregiver being improperly trained, being ignorant of correct interactions, or simply being unable to deal with the stresses of his or her job. On the other hand, such actions might be the result of the caregiver attempting to punish the resident for some reason, such as being uncooperative.

It has also been found that physical abuse often accompanies psychological abuse, so patients are at risk of receiving a double dose of mistreatment. To place this problem in perspective, note that a random survey of nurses’ aides in nursing homes found that 40% admitted to at least one act of psychological abuse in the previous 12 months. This is a very broad category and it is very important to the resident’s mental health.

Although many researchers are in agreement that emotional abuse is very much under-reported, it is surprising to learn that physicians are part of the problem. Studies have reached the conclusion that physicians are less effective than other groups of professionals in identifying abuse, and that they are generally not aware of the legally mandated reporting. Additionally, they are often unaware of the many resources that are available to help them in this regard.

Because of the broad definitions in this category, it is difficult to accurately track the number of incidents that are actually occurring; however, by looking to the state agencies that investigate and prevent this sort of abuse, they all report that their caseloads are increasing.

False Imprisonment

This occurs when a patient is unreasonably confined to a particular area, such as his or her room, or a particular portion of the facility by the nursing home staff. Perhaps they feel the patient has been uncooperative, abusive or just difficult to work with. They may threaten the patient with the withholding of food or water, or removing crutches or a wheelchair from their access.

Withdrawal or Social Isolation

Another problem to be alert for is withdrawal or social isolation of patients. Stress among patients or between patients and an overworked staff can lead to a patient’s withdrawal or social isolation. This could also fall under emotional abuse. This behavior can be a symptom of abuse by staff or other residents and care should be taken to determine the cause.

Social isolation can come about when the patient refuses to participate in any of the available social activities, including watching television in a community setting, playing games, or participating in other group activities. It can also lead to withdrawal, where the person does not want to leave their room, speak to caregivers, other patients, or even relatives.

If withdrawal or social isolation does occur, the doctor may institute a combined therapy of drugs and psychiatric intervention. Before such treatment is applied, you should insist on an evaluation for non-medical evidence of abuse that may be causing your loved one to become withdrawn.

Centers for Disease Control and Prevention
National Center on Elder Abuse, Administration on Aging
The New England Journal of Medicine

Sexual Abuse or Sexual Assault

Sexual assaults can and do happen in nursing homes and assisted living facilities. A sexual assault occurs when the patient takes part in a sexual act without giving their consent. Keep in mind that the patient must have the mental capacity to make an informed decision about a sexual act.

Nursing home patients, regrettably, often provide a sex abuser a prime target for this crime. These victims often suffer from the inability to properly communicate to others what is actually happening to them. Having Dementia is a prime example of how a patient could be repeatedly taken advantage of and not have the ability to report this type of incident. Of course force could be used in conjunction with the event, but it could also be completed under the threat of the denial of food, water, or even their required prescription medication.

Some care and medical procedures require baring of the body and touching of sensitive areas. This opens the opportunity for going “too far” and crossing over to abuse. Further compounding this problem is that police investigators are not often trained in how to conduct a proper interview with an ill, elderly person suffering from diverse medical issues. This is a highly specialized area that may not often come up in the course of their work. In addition, something as simple as documenting bruises is not quite as straightforward as it seems. A study conducted by the University of California, Irvine, documented the progression of accidental bruises found on elderly patients. They found that color is not a good indicator of the age of the bruise and that some medications affect the coloring. Investigators are taught about the general color progression of bruises as they age, however most often they would not be told how medications for geriatric patients might change those colors.

A lack of security in the nursing home or assisted living facility can also provide an opportunity for a stranger to gain access to the building and commit this type of crime. This is why it is essential that personnel monitor whether exterior doors are locked, and require visitors to sign a log to enter.

Even spouses can be involved in sexual abuse. Remember that the patient must have the capacity to make an informed decision concerning sexual contact. Advanced Alzheimer’s patients may not recognize their spouse and be terrified that a “stranger” is touching them.

If other patients have psychiatric issues, it is the nursing home’s responsibility to ensure that they have no chance to prey on other residents. They might even have a history, unbeknownst to you of course, of prior sexual assaults or sexual violence.

It is the duty and responsibility of the nursing home staff to monitor such activities to prevent unwanted sexual relations.

Centers for Disease Control and Prevention
National Institute of Justice

Assault and Battery by the Nursing Home Staff

In many instances, nursing home may have decreased or lost their physical and cognitive abilities, and now have a childlike view of their world. The stresses and pressures of meeting the daily needs of these residents are multiplied by the pressures of the job: Inadequate time to perform daily chores, unceasing demands of residents, and a higher and higher work load with no relief from administration. In addition, some residents may make unreasonable demands of caregivers, and may even strike caregivers, without realizing what they are doing due to mental illness or the loss of their mental functions.

This could lead to a physical confrontation involving the caregiver and the patient.
Of course, this does not justify physically striking a patient; however, these types of situations can shed light on how this can develop. An assault can be simply verbal abuse, while a battery occurs when there is unlawful physical contact. From these definitions, you can easily see that there is a very broad scope of behavior that falls under this category.

These can be extremely dangerous incidents, even involving the death of a patient. Also, these types of problems are often difficult to recognize and are often not properly reported. In one study, over one-third of the staff of a nursing home admitted witnessing physical abuse, and over 80% admitted to actually witnessing psychological abuse in the previous year.

Other figures may be more telling. Over one-half of a nursing home’s staff admitted to angrily yelling at a patient, and 17% said that they had taken a hold of (grabbed) or pushed a patient during a one-month time period.

So, if you are seeing bruises, abrasions, or lacerations on your relative who is a nursing home patient, do not ignore it. Some follow-up investigation may be needed.

Injury Prevention Journal
Psychiatric Services Online; the American Psychiatric Association.
 Confronting Elder Mistreatment in Long-Term Care. Lisa M. Gibbs, MD, and Laura Mosqueda, MD.

Physical Abuse

It is hard to imagine a situation where nursing home staff would intentionally cause active, physical harm to a patient, but sadly it does occur. If an attendant has slapped, pinched, kicked or in any other way physically harmed a nursing home resident, this is physical abuse that must be reported to management and may be serious grounds for pursuing a nursing home abuse lawsuit.

Restraint or Strangulation Injuries

Ethics plays a huge role in the use of physical restraints. There are many concerns here, including social and psychological considerations, and all should be thought through completely by the medical professionals considering this course of action. This is especially important considering that one study recorded a prevalent use of restraints–up to an 85% use of physical restraints in nursing homes.

Examples of physical restraints are: use of a secure vest, limb ties, tucking sheets in too tightly, wheelchair bars, bedside rails, chairs that tip backwards, and straps. The essential points of a physical restraint are a device or material that cannot be easily removed by the person and that it is intended to stop free bodily movement by that person.

There are a number of consequences from the use of physical restraints and these hazards are increased when an elderly patient is involved. For example, the use of restraints may increase health related issues to the patient. These could include:

• Under nutrition
• Incontinence or constipationphysical abuse
• Bruises
• Complications in respiration
• Ulcers
• Loss of balance and muscle strength
• Loss of cardiovascular health
• Agitation

Generally, the use of physical restraints causes a feeling of dependency, and a loss of self-respect and dignity. There are exceptions. For instance, bedrails and wheelchair bars have been reported to make the patient feel safer and more secure. However, agitation, aggression, and anxiety may increase and are not uncommon results.

A number of ethical considerations should be addressed when evaluating the use of physical restraints. Some of these are:

• A person’s autonomy
• Dignity
• Self-reliance
• Considering the overall health and welfare of the patient

The staff should conduct an analysis to make certain the final decision to restrain the patient outweighs the potential negatives involved. The items considered should include the current drug therapy, emotional state, health, mobility, prior history, and the current psychological state. The first choice of restraints should always be the least restrictive method available. If that choice proves ineffective, a more restrictive method could be tried next. It is important that the family is made aware of the intent to restrain the patient in any way for legitimate reasons.

A policy should be in place for escalating restrictive methods used on patients, beginning with the least restrictive; further, each escalation should prompt another, albeit shorter, cost-benefit analysis to ensure that the next escalation is the right decision for the patient.

This is a difficult decision that should involve all the parties concerned, including the management staff of the nursing home, caregivers, doctors, relatives, and as much as possible, the patient. Of course, some patients will be unable to provide any meaningful input because of their mental state. This is where the relatives should actively participate in the decisions that are being made. By involving the relatives in such decisions, there is a mutual understanding of why restrictive methods may be necessary, which serves to clarify any misunderstandings.

National Center for Biotechnology
European Academy for Medicine of Ageing