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Abuse in care facilities is a problem occurring around the world, with negative effects. Elderly, disabled, and cognitively impaired residents are the most vulnerable. It is the duty of direct caregivers to ensure that their residents are protected from danger and harm. This educational program will discuss various types of resident mistreatment and the psychological, physical, and financial effects. It will also discuss ways that employees can prevent, report, and cope with abuse cases in a senior living community. 8

Residents in senior living communities are at risk for various forms of theft. Some residents are alert and oriented but physically disabled. Some are physically capable but cognitively challenged. This puts them at risk for identify theft, embezzlement, petty thefts and other forms for stealing. In addition they can be teased by staff. They may be treated in a manner that is not respectful of who they once were when they were fully functioning. It is hard to imagine that a person who was once high functioning in society may find themselves stranded in a room calling for assistance to go to the toilet with no one to help. 9

In the United States the definition of abuse can vary. Abuse includes emotional abuse, neglect, exploitation, abandonment and self-neglect. Laws protect the general population, regardless of the victim s age. For example, criminal laws related to murder, assault, battery, rape or sexual assault do in fact protect older adults. Individuals can be arrested for a wide variety of illegal acts related to resident abuse. Direct caregivers must maintain a safe environment for the residents. 10

The most common form of elderly abuse is financial exploitation. In New York it was found that financial exploitation was related to cognitive deficits, home ownership, advanced age, and an inability to manage finances. In these cases, the abusive individual is typically a nonrelative who has known the elderly person for a short amount of time. Most cases are scam phone calls instructing the elderly person to reveal their bank account and social security numbers in order to receive their lottery winnings. This can cause financial loss and also identity theft. 11

With financial abuse, the best place to start is to observe behavior. There are certain warning signs that residents are vulnerable: poor physical health, cognitive impairment, difficulty with daily activities, and social isolation. Those with poor physical health are less likely to focus on financial matters, whereas those with cognitive impairment struggle to read banking statements. If an individual has difficulty with daily functions, they may also have trouble handling money. Lastly, if a person lacks a network of peers, they are more prone to money scams. Often the abusers are people who have developed a trusting relationship with residents. This makes elders easier to manipulate, even if they are mentally competent. Abusers may see themselves as deserving of rewards, and coerce victims into financial support. A resident s family and social network involved can help curb financial abuse. It is important to be aware if a resident comes across scams masquerading as unique investment opportunities, or if they have made suspicious, new friends. Remind employees to observe patients when they visit with friends and family. 12

It is important to differentiate various forms of elderly maltreatment and their respective risk factors. There are several risk factors that make residents susceptible to non-physical abuse. The evidence supports that social isolation and dementia put residents at the highest risk of non-physical abuse. Elderly residents who don t have children or significant others, and are mentally/physically dependent on staff are more prone to abuse. These residents may be unable to manage their own finances and are thus vulnerable to nonphysical abuse. 13

The psychological effects of resident abuse are numerous. There is documentation that residents who suffer physical abuse are at risk of cardiac issues, such as Broken Heart Syndrome. It is possible that there are physical and psychological ramifications to nonphysical abuse. When the expectation of trust is broken between caregivers and residents, residents may experience psychological effects including depression, anxiety, disorientation, and fear of caregiver. 14

While necessary to understand the various forms of resident maltreatment and their respective risk factors, it is also important to be aware of common abuser characteristics. In circumstances of financial exploitation, abusive individuals are non-relatives who have known the elderly person for a short period of time, and are less likely to have children. Caregivers who are economically troubled can become financially dependent on residents who have dementia or are advanced in age. In the case of neglect, abusive individuals may be overburdened by the support required of them to care for residents. Caregivers can become overwhelmed by work stress and develop abusive characteristics when they are unable to handle geriatric care. Staff risk factors include: staffing shortage, poor training and supervision, and poor working conditions. Studies have shown that educational support group intervention is effective in reducing negative psychological behavior and increasing geriatric knowledge in caregivers. These groups function as both a mutual support group which also incorporate knowledge in geriatric care. Continuous ongoing training for staff in the care of the residents is necessitated to curb elder abuse. 15

Elder maltreatment is a phenomenon that effects care facilities across the country. However, there are certain demographics of people that are at higher risk of nonphysical resident abuse. According to the Adult Protective Services database, nonphysical abuse victims, were on average 78.6 years of age. Additionally, 66.5% were female and 66.5% were White. Over half of the victims were widowed, and had known their abusers for an average time of 22 years. Women with advanced age are at a higher risk of financial exploitation and neglect. It is also possible that without the support of a partner, individuals are more vulnerable to financial scams and social isolation. Additionally, victims know their abusers for a long enough time to establish a trusting relationship. In other words, a long standing relationship does not necessarily mean there aren t cases of elderly maltreatment. 16

Direct caregivers at a care facility must be aware of risk factors for different forms of abuse, so that they may protect residents. They need to understand the available demographic data about abusive individuals. According to the Adult Protective Services database, the majority of nonphysical abusive individuals are white and male, and more likely to be a nonrelative. These individuals are also more likely to feel exhausted and underpaid at work. Since many victims of financial exploitation are elderly with few relatives, the risk of the abuser being caught and prosecuted is diminished. This data shows that employees are more likely to financially take advantage of or neglect residents if they fit this description. If employees are becoming abusive due to work stress and inability to cope with geriatric care, they need a more dynamic support system for employees. 17

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Social isolation in a home environment has a strong correlation to abuse by a trusted caregiver especially if there are limited family or friends to supervise care. People in this situation are dependent on caregivers and may tolerate inappropriate behavior in order to have their primary needs met. It is important to note that social isolation can occur in a senior living community as well. In senior living communities direct caregivers should function as an advocate for residents and be alert to signs of people who may be taking advantage of or mistreating residents. Senior living communities can offer support and protection to residents that they lack in a home setting. The experience of living with others can in fact increase social opportunities for the resident which in turn may help them to resist or report abuse. 19

A 2013 survey categorized residential or in-home services settings as follows: Family Home: A residence of person(s) with IDD which is also the home of related family members in which the person(s) with IDD and/or their family members receive supportive services (e.g. respite care, homemaker services, personal assistance). Host home/foster Family: A home owned or rented by an individual or family service provider in which they live and provide care for one or more unrelated persons with IDD. Group Home: A residence of any size owned, rented or managed by the residential services provider, or the provider s agent, to provide housing for persons with IDD in which staff provide care, instruction, supervision, and other support for residents with IDD. Psychiatric Facilities: state residential facilities designed for persons with a primary diagnosis of a psychiatric disabilities, (for example a mental health facility) in which one or more residents with a primary or dual diagnosis of IDD lives. Other state-operated settings: state-operated facilities or units within facilities that are specifically designated to serve people with IDD that are funded with resources other than the ICF/IID or the Medicaid HCBS Waiver programs. 20

Intermediate Care Facilities for individuals with Intellectual Disability (ICF/IID): an optional institutional Medicaid benefit that enables States to provide comprehensive and individualized health care and rehabilitation services to individuals to promote their functional status and independence. Although it is an optional benefit, all States offer it, if only as an alternative to home and community-based services waivers for individuals at the ICF/IID level of care (Medicaid.gov). Nursing home: A Medicaid-funded institutional setting offering skilled nursing or medical care and related services; rehabilitation supports needed due to injury, disability, or illness; and/or long-term care including healthrelated care and services (above the level of room and board) not available in the community, needed regularly due to a mental or physical condition. Own home: A home owned or rented by one or more persons with IDD as the person(s) own home in which personal assistance, instruction, supervision and other support is provided as needed. In settings classified as Own Home, the service recipient is able to remain in the home if the provider of services changes whereas in provider owned or operated facilities, changing the service provider requires the recipient to move to a new setting. 21

There are several ways to assess resident abuse in a care-taking facility. It is the responsibility of the direct caregivers to be aware of the resident s baseline condition in order to take note of unusual circumstances. If the resident is a perceived victim of abuse, the employee s role is to report the incident to their manager. All states have an agency tasked with investigating reports of suspected elder abuse. For more information, refer to the National Center of Elder Abuse s website. In elder abuse cases, prosecution is rare for many reasons. Reporting to the Adult Protective Services increases chances of legal cases being filed at a defense attorney s office. Financial exploitation cases have the highest rates of prosecution. However, criminal prosecution should be the last resort when dealing with nonphysical abuse cases. Criminal prosecutions also occur less often due to the victim s inability to testify. A more psychosocial approach, such as a support group, may serve victims better overall and save them from legal fees. 22

Direct caregivers should recognize different theories of abuse and understand why elderly people are particularly vulnerable. These theories are based on multiple disciplines, such as psychology, biology, and sociology. Social Exchange Theory: Resident abuse may occur because of the victim s dependence on the abuser and vice versa. An abuser might financially exploit a victim who is physically or mentally dependent on the abusive individual Feminist Theory: Focus mainly on spousal elder abuse. Elderly women are particularly vulnerable to their partners because men tend to have more social and financial resources. Psychopathology of the caregiver theory: Caregivers who have mental illness, a family history of abuse, or abuse alcohol are more likely to be abusive towards residents. Role Accumulation Theory: Elderly residents may be abused by family members with conflicting role obligations, who are unable to cope well with stress management. 23

A continuation of discussing theories of abuse, based on psychology, biology and sociology: Situational Theory: One of the earliest and most widely accepted theories of elder abuse. This theory concerns the everyday stress of caregiving. An overwhelmed caregiver who cannot cope with such a stressful work environment may become abusive towards vulnerable residents. Social Learning Theory: States that violence is a learned behavior passed on between generations. If an individual has a family history of violence, they may think violent behavior is acceptable. The abused individual might continue the cycle of violence in a care home facility. Stratification Theory: This form of abuse is particularly found in caregivers. When a caregiver receives low pay and little recognition, they may abuse residents as a need to gain control and compensate for low status. 24

Direct caregivers should regularly review with managers proper procedures for reporting suspected abuse. Senior living facilities should have facility specific policies and procedures for reporting elder abuse that align with the state mandated elder abuse reporting laws. Those references should be easily available and accessible. If a resident s life is in danger, this should be reported to 9-1-1 immediately. If a non-life-threatening situation of elder abuse is suspected, the facility should contact Adult Protective Services (APS) within 24 hours, the long-term care ombudsman, and/or the local police department. Most states have 24- hour hotlines available for elder abuse reporting. Adult Protective Services keeps a permanent record of employees who have been charged with elderly maltreatment. Whether an incident against a nurse is determined to be founded or unfounded, the Board of Nursing is notified. 25

Each state has specific laws addressing elder abuse. As a direct caregiver in a senior living facility, you should know about regulations in your state. Additionally, employees need to be aware of potential barriers to abuse reporting. The prosecution requires many public resources from the district attorney s office, Adult Protective Services, and law enforcement. This puts a budgetary strain on the court system. Secondly, there are individual ramifications for reporting elder abuse. Victims may experience a fear of retaliation, and/or the feeling that nothing will be done if the abuse or misconduct is reported. These anxieties are exacerbated if the staff lacks knowledge about identifying signs and symptoms of abuse. There is also a fear that the staff employee reporter may feel that the abuse happened on their watch, thereby resulting in employee discipline or suspension. 26

Suspected misconduct must be reported to the appropriate Adult Protective Services agency as identified by individual state laws (usually within 24 hours). As soon as elder abuse is suspected, the employee must first make sure the resident is safe. Contact local police if the resident suffered serious physical injury or theft. Do not handle any evidence until after law enforcement arrives and conducts their investigation. The employee identifying the abuse situation should notify the charge nurse and/or middle manager so that the resident can be properly assessed for trauma. This assessment should include detailed documentation of any abnormal behavior and injuries. A facility incident report should be completed by the middle manager. They must interview the resident, eye-witnesses and suspected abuser separately. The facility supervisor or senior manager should then perform follow-up interviews with the resident and suspected abuser. A standard protocol must be set so that the facility has a familiar and exact procedure to follow in each report of abuse. All staff should be continually educated and familiar with this exact procedure. 27

Direct caregivers should immediately report suspected resident maltreatment to senior management because managers can help prevent resident abuse by reviewing paperwork for all newly hired employees. Background checks should include abuse registries as well as criminal background. Older adults who reside in senior living facilities should be encouraged to have advance directives, living wills, and limited power of attorney designations for financial and healthcare decisions. They must be mentally able to understand and sign these legal documents. These few steps can help reduce the risk of staff personnel exploiting or abusing residents. Furthermore, it is important to account for which residents are at highest risk of nonphysical abuse. Residents who have dementia, physical disability, advanced age, and/or are without a close network of friends or family are at the highest risk of abuse. 28

Not only does filing criminal charges for abuse pose a series of financial and logistical barriers, but it s also unclear if this avenue is the most psychologically helpful for victims and abusive individuals. Alternative efforts to prevent or remedy the abuse case early are preferable to criminal prosecution. Studies show that educational support group intervention is effective in reducing negative psychological behavior in caregivers while also increasing their geriatric knowledge. When organized carefully, educational support groups have important implications for caregivers. Studies have shown that many caregivers neglect residents because they are overwhelmed by their work environment and illequipped to deal with vulnerable populations. Individuals who participated in a group which incorporated both mutual support and geriatric education experienced a decrease in psychological elder abusive behaviors. 29

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