RESIDENT ABUSE IN NURSING HOMES 
UNDERSTANDING AND PREVENTNG ABUSE 
Richard P. Kusserow

INSPECTOR GENERAL

OEI-06-88-0060 
APRIL 1990
 , '

EXECUTIVE SUMMARY 
PURPOSE AND BACKGROUND 
The GIG conducted this study to promote a better 
understanding of abuse in nursing
homes. This is the first of two reports. It 
examines the nature of abuse and ways to
prevent it. The second report  Resident Abuse in Nursing Homes: 
Resolving Physical
Abuse Complaints  examines existing processes for resolving physical abuse 
complaints. Both reports reflect the 
experiences and perceptions of knowledgeable
individuals who 1) play some part
, directly or indirectly, in the resolution of abuse
complaints, or 2) have an interest in 
nursing home or elder issues. 
Abuse of the elderly is not a new phenomenon. Research findings and 
Congressional hearings of the 1970s and 1980s helped to increase. public awareness
of elder abuse. However, little research has focused on the 
issue of abuse of nursing
home residents; certainly, no national 
survey has been initiated. 
Existing studies of
abuse focus primarily on family members and 
caregivers in their homes. 
Research
indicates from 1 to 10 percent of the non-
institutionalized elperly population may be 
subject to abuse.

While there are no exact statistics on institutional abuse
, any abuse is unacceptable.
Each incident  major' or 'minor,' may be a terrifying experience and a 
significant
breakdown in the responsibilty of government to assure a safe and 
caring
environment for elderly and disabled 
individuals. The price for abuse is measured in 
the physical and psychological harm to the resident as well as by the economic 
costs
of treating the abused resident. 
METHODOLOGY 
The term abuse covers many problem areas for nursing home residents ranging from 
environmental conditions needing correction to actual mistreatment of residents. 
For 
purposes of this study, abuse is defined as mistreatment or neglect of nursing home
residents encompassing the 
following seven categories: 
Physical abuse 
Misuse of restraints 
Verbal/emotional abuse 
Physical neglect 
Medical neglect 
Verbal/emotional neglect 
Personal property abuse  Since national abuse statitics are not available and states vary in how they define and 
collect statistics, we decided to survey knowledgeable individuals involved directly or 
Specifically, the inspection relied on 232 intervews 
indirectly with nursing home care. 

with respondents representing State, Federal and national organizations which are 
either 1) involved with receiving, investigating and/or resolving nursing home abuse 
complaints, or 2) knowledgeable and concerned about nursing home or elder issues. 
A minimum of three principal entities were intervewed in each of the 35 sample 
States: (1) State Ombudsman, (2) investigator or director of State Medicaid Fraud 
Control Unit (MFCU), or legal counterpart where no MFCU exists, and (3) State 
nursing home complaint coordinator (the nursing home administrators' primary 
contact for abuse complaints). These entities were selected because our 
pre inspection indicated they were the most often involved in nursing home abuse 
complaint receipt and resolution in most States. 
Respondents, based on their functional expertise and knowledge, answered a wide 
range of questions about different aspects of abuse in nursing homes including their 
perceptions of the prevalence and severity of the seven abuse categories listed above. 
The experiences and perceptions of the participants coupled with a review of State 
and Federal policies provide the basis for the findings and recommendations of this 
report. 
MAJOR FINDINGS 
Nearly all respondents indicate abuse is a problem in nursing homes. 
Respondents differ, however, regarding the severity of the problem. A majority 
of the State oversight agencies and resident advocates for nursing homes perceive 
abuse as a serious problem, while many nursing home administrators and industry 
representatives perceive the problem as minor. 
Physical neglect, verbal and emotional neglect, and verbal or emotional abuse are 
perceived as the most prevalent forms of abuse.

Nursing home staff, medical personnel, other patients and family or visitors all 
contribute to abuse. However, aides and orderlies are the primary abusers for all 
categories of abuse except medical neglect. 
Respondents believe nursing home staff lack training to handle some stressful 
situations. 
Most respondents believe staff certification and training will help to deter 
resident abuse.
 Administrative or management factors also contribute to nursing home resident 
abuse (e.  , inadequate supervsion of staff
, high staff turnover, low staff to
resident ratios). 
RECOMMENDATIONS 
Because this inspection indicates abuse may be a problem for 
nursing home
residents, we recommend the following: 
The Health Care Financing Administration (HCF A) 
should: 
Require, as part of its nurse aide 
training regulations
, ongoing
training concerning the aging process and 
mechanisms to cope with
and avoid confrontational situations. Further, nursing homes should
be required to document staff training and 
understanding of abuse
and reporting 
responsibilities and procedures for abuse 
incidents. 
Require, as part of the admission requirements for a new resident
nursing homes to inform residents about 
differences between living
in a nursing home environment 
vs. living at home, possible problems
they may encounter
, and ways to deal with such 
problems. 
Require, as part of its conditions of participation for nursing homes 
supervsory and training staff to acquire 
skills necessary to effectively
train and supervise paraprofessional and nonprofessional staff. 
The HCFA should further support research 
concerning long term care
policies which promote staff stabilty and provide for 
adequate staff-to
patient ratios necessary to control stress and abuse. 
The Administration on Aging (AoA) should collect and disseminate 
information about nursing home practices 
which avoid stress and abuse 
and promote staff stabilty and adequate 
supervision.  DEPARTMENTAL COMMENT 
This report has been modified to reflect many of the comments 
received from within 
and outside the Department of Health and Human Servces. Comments from the 
Assistant Secretary for Planning and Evaluation, the Office of Human Development 
Servces, the AoA, and HCFA are included in the appendix to the report. They 
generally agreed with our findings and recommendations. The HCFA indicates it has 
already done much to accomplish the recommended changes.  TABLE OF CONTENTS

Pag 
EXECUTE SUMMARY

INTODUCTION

Purpose

Background

Scope and Methodology

FINDINGS 
Nearly all respondents indicate abuse is a problem in nursing 
homes. 
Respondents differ, however, regarding the severit of the problem. A majorit

of the State oversight agencies and resident advocates for nursing homes

perceive abuse as a serious problem, while many nursing home administrators

and industry representatives perceive the problem as minor.

Physical neglect, verbal and emotional neglect, and verbal or emotional abuse

are perceived as the most prevalent forms of abuse.

Nursing home staff, medical personnel, other patients and family or visitors all

contribute to abuse. However, aides and orderlies are the primary abusers for

all categories of abuse except 
medical neglect. 
Respondents believe nursing home staff lack training to handle some stressful 
situations. 
Most respondents believe staff certification and training wil help to deter 
resident abuse. 
Administrative or management factors also contribute to nursing home resident

abuse (e.g., inadequate supervision of staff, high staff turnover
, low staff to

resident ratios).

RECOMMENDATIONS 
DEPARTMENTAL COMMENTS 
APPENDICES 
Appendix A.  National Organization Respondents

Appendix B.  Tables I-VII: Respondent Perceptions

on Abuse Categories as Problems

Appendix C.  Departmental Comments

Appendix D.  Public Comments

Appendix E.  Bibliography
 -.. -..-.. -..-
ACTUAL AND PROJECTED GROWTH OF THE ELDERLY 
POLATION (65 YEARS OLD) 
NUMBER (IN MILUONS) 
PERCEN OF POPULATI 
20 -..-..-..-.. 
10 -.. 
1970 198 199 200 2010 2020
YEAR 
&O aR POT1 RES 
CE NBOl. U81  
us 
NUMBER (IN MILLIONS) 
PERCENT OF POULATION 
FIGURE 1 
PROJECTION OF THE NURSING HOME POPULATION 
GRP 
65 YEAS AND OLER BY AGE 
en 4 
lEas AND OVER

75 - 84 
065
20 
Z 0

198  1990  2010  2020  II
YER  8O AG.- 118..1D
"'AI 
8Y u.s. 8A8'MIT  IONAC 
AGUR 2
 INTRODUCTION

PURPOSE 
The OIG conducted this 
study to promote a better understanding of abuse in nursing
homes. This is the first of two reports. It 
examines the nature of abuse and ways to
prevent it. The second report  Resident Abuse in Nursing Homes: 
Resolving Physical
Abuse Complaints  examines existing processes for resolving physical abuse 
complaints. Both reports reflect the 
experiences and perceptions of knowledgeable
individuals who 1) play some part, directly or indirectly, in the resolution of abuse
complaints, or 2) have an interest in nursing home or elder 
issues. 
BACKGROUND 
Americans are living longer, and the nation s elderly population is growing at an
unprecedented rate, partially as a result of new technologies and medical advances.
There are now 28 miIion people aged 65 or 
older; by 2030, they wiI number more
than 60 miIion
, or 21.2 percent of the total population (figure, 1). As individuals live
longer, their need for nursing home care may increase. 
While only about five percent of the elderly 
population are in nursing homes at any
given time, it is likely the nursing home population 
wiII continue to grow rapidly
the very old segment of the population 
continues to expand. Projections indicate 3.
miIion elderly individuals will be living in nursing homes by 2030 (figure 2). 
The
growth in the number of older people 
experiencing both disabilities and
dependencies may place additional physical and emotional stress on both 
institutional 
and non-institutional caretakers. Persons advanced in age, limited by mental and/or
physical impairments and dependent on others for 
their daily care, constitute the
population most vulnerable to abuse. 
Abuse of the elderly is not a new phenomenon. Research findings and
Congressional hearings of the 1970s and 
1980s have helped to increase public 
awareness of elder abuse. Existing studies of abuse have focused primarily on 
family
members and caregivers in their own homes. Research indicates from 1 to 10 
percent of the non-institutionalized elderly may be subjected to abuse. 
The incidence
of and facts concerning institutional resident abuse are less 
known. 
Doty and Sullvan (1983) note that both Federal and State 
sources report receipt of
incidents of resident abuse each year. Monk
, Kaye, and Litwn (1984) found that
State Long-Term Care Ombudsmen receive many complaints about nursing home  , '

staff treatment of residents. Further, they note a substantial amount of maltreatment 
is never reported. 
PiIemer and Moore (1988) provide one random survey designed to assess the scope 
and nature of physical and psychological abuse in nursing homes. They found 
that 36 
percent of the sampled nurses and nurse aides had seen at least 1 incident of 
physical abuse in the preceding year; 10 percent reported they had committed 1 or 
more physically abusive acts. 
While there are no exact statistics on institutional abuse, any abuse is unacceptable. 
Each incident  major' or 'minor,' may be a terrifyng experience and a significant 
breakdown in the responsibilty of government to assure a safe and caring 
environment for elderly and disabled individuals. The price for abuse is measured in 
the physical and psychological harm to the resident as well as by the economic costs 
of treating the abused resident. 
Federal Roles 
Three Department of Health and Human Services (HHS) agencies have either direct 
or indirect involvement with nursing homes and servces to residents of nursing 
homes: the Office of Human Development Servces/Administration on Aging 
(OHDS/AoA), the Health Care Financing Administration (HCFA), and the Office 
Inspector General (OIG). 
Administration on Aging 
The Administration on Aging (AoA) of OHDS is the primary Federal agency 
responsible for the State Long-Term Care Ombudsman (hereafter referred to as 
State Ombudsman) program. It further serves as the visible advocate for the elderly 
within HHS. The AoA meets the needs of the elderly mainly through a program of 
grants to State Agencies on Aging under Title III of the Older 
Americans Act 
(OAA) (as amended (42 D.  C. 3001 et seq. authorizes activities for 
)). Title III also 
the prevention of elder abuse. The Act requires each State Agency on Aging to 
establish and operate a State Ombudsman program to receive and review complaints 
concerning nursing home residents. 
Health Care. Financing Administration

The HCFA administers Medicare and Medicaid program operations. Within HCFA, 
the Health Standards and Quality Bureau (HSQ) has 
oversight responsibilty for 
Medicare and Medicaid nursing home standards of care 
designed in part to ensure 
an environment free from abuse. To meet this obligation, HCF A develops and 
administers the regulatory requirements for nursing homes participating in either 
Medicare or Medicaid, develops training requirements for surveyors who conduct  nursing home inspections, conducts yearly compliance surveys of five percent of those 
facilities previously surveyed by the State, and monitors State compliance surveys for 
quality assurance. 
The HCF A may directly receive complaints of abuse 
involving nursing home
residents. However, these wil 
usually be referred to the applicable State agency for
nursing home certification unless the allegation 
involves an "immediate and serious 
threat" to patient health and 
safety. 
Office of Inspector General 
Through Public Law (P.L.) 94-505, enacted in 1976, the OIG was established as an 
independent unit in HHS with the authority to prevent and detect fraud and abuse 
in Department programs. The OIG is required to 1) recommend policies for the
detection and prevention of fraud and abuse within 
programs and operations
administered or financed by the Department and 2) conduct
, supervise, or coordinate
investigations related to such fraud and abuse. 
Under Section 1128 of the Social Security Act, the OIG was provided authority to
impose sanctions against health care providers convicted of Medicare or 
Medicaid 
offenses or suspended or excluded or otherwise legally or 
administratively sanctioned
by appropriate State entities. In meeting this statutory authority, the OIG works 
with other Federal, State, and local governmental agencies and nongovernmental
entities. As a further part of this authority, the OIG/Office of Investigations (01)
has oversight of and grant certification responsibility for 
State Medicaid Fraud 
Control Units (MFCUs). 
The Medicare and Medicaid Patient and Program Protection Act of 
1987 amends 
titles XI, XVIII, and XIX of the Social Security Act to protect beneficiaries from 
unfit health care practitioners. The Act states that if an 
individual is convicted of 
patient abuse in connection with the delivery of a health care item or service 
exclusion from the Medicare and Medicaid programs is 
mandatory. 
In September of 1986, the OIG/OI published an "Investigative Guide for the
Detection of Patient Abuse." The guide was made available to State MFCUs for 
training and reference purposes. 
Existing Nursing Home Requirements 
The Medicare and Medicaid programs traditionally have used a condition of 
participation (COP) format to define requirements 
which must be met by facilties in
order to participate in the programs. This format is based on the principle that each
condition level statement would be a statutory requirement while standard level 
statements would be lesser requirements within a condition.  Under current law, a skiIed nursing facility (SNF) must meet COPs to participate in 
the Medicare or Medicaid programs; intermediate care facilties (ICFs) must meet 
standards. Current COPs and standards were originally published in 1974. The 
SNFs have a single uniform definition which extends the same level of care 
requirements to both Medicaid and Medicare programs. The ICF benefit was 
intended to allow facilties which did not meet SNF COPs to participate as ICFs and 
provide health-related care , to Medicaid patients. 
, not at the skilled level
Provisions for resident rights are ambiguous and enforcement is difficult because a 
resident's rights and a facility s obligations are sometimes unclear. Recognizing that 
a resident s rights, living conditions, and medical care are essential components of the 
quality of life in a facilty, HCF A developed outcome oriented survey instruments in 
June 1988. The emphasis of current regulations is on process, not outcomes of that 
process as is relates to residents. The regulations do not contain any SNF COP or 
ICF standard for a resident assessment. Also, there is no quality of care COP 
utilzing resident care outcomes, especially negative ones, to assess whether residents 
are receiving satisfactory care. 
Existing Medicare COPs are located at 42 CFR, Part 405, Subpart K and implement 
Section 1861U) of the Social Security Act. Current Medicaid standards are in 42 
CFR, Part 442, Subparts D, E, and F. 
Omnibus Budget Reconcilation Act of 1987 (OBRA ' 87). P.L. 100-203 
On December 22, 1987, OBRA '87 was enacted. The law includes extensive 
revisions to the Medicare/Medicaid statutory requirements for nursing facilities. 
Nursing home reform provisions, to be implemented October 1, 1990, establish 
uniform requirements for Medicaid SNFs and ICFs. The law revises the conditions 
under which nursing homes may participate in the Medicaid/Medicare programs, the 
process for monitoring compliance with law, and the remedies available to Federal 
and State agencies in the event of noncompliance. It further expands nursing facilty 
resident rights to include freedom from 1) inappropriate use of physical or chemical 
restraints and 2) physical or mental abuse or punishment. 
The NF (any Medicare SNF or Medicaid facilty which is not an ICF for the 
mentally retarded) must inform residents orally and in writing . of their legal rights. 
The HCFA draft regulations provide all incidents of abuse be reported to the 
nursing home administrator of to any other agency designated by State law. 
Residents may fie a complaint concerning abuse or neglect with the State 
survey/certification agency. The NF must permit the State Ombudsmen access to the 
resident and the resident's clinical records with the permission of the resident or the 
resident s legal representative.  The NFs wil be required to verify the competency of applicants prior to their
employment as nurse aides. No nurse aide may be employed for more than four 
months unless the individual has completed State-approved training or 
successfully
passed a competency test. Verification of a nurse aide s competency will be
strengthened through the required use of a State maintained 
nurse aide registry.
This registry will certify that the individual has 
met the required training
requirements and indicate the documented findings
, not limited to convictions, of
resident abuse, neglect, or misappropriation of resident property 
involving an
individual listed in the registry. If the State determines a nurse aide has been 
involved in these activities, the State wil, after notice and reasonable opportunity to
rebut allegations in a hearing, notify the nurse aide and the nurse aide 
registry. 
State and Local Roles 
The primary responsibility for designing, operating, and coordinating 
services for the 
Several State agencies may be responsible for 
elderly lies with the States.  resolving
nursing home problems including: 
nursing home complaint coordinators 
State Ombudsmen (under the direction of the State 
Agency on Aging),
MFCU or other legal authorities where no MFCU is established 
agencies for nursing home certification and licensure 
licensure agencies for medical personnel 
adult protective services, and 
local law enforcement. 
The nursing home complaint coordinator is the individual 
designated to nursing home
administrators as the central State authority to receive 
complaints of mistreatment or
neglect of nursing home residents. This individual may be in any 
number of State 
agencies or part of a designated complaint unit, but is usually a staff member of the
State nursing home survey and certification 
agency. 
The State Agency on Aging, through the State Ombudsman
, is required by the OAA: 
1) to establish procedures for maintaining a State-wide reporting system to
collect and analyze data related to complaints and incidents; 
2) to monitor the development and implementation of Federal
, State, and local
laws, regulations, and policies with respect to long term care in the State; 
3) to provide public education on their activities and long term care 
issues; and 
4) to 
promote training and certification of 
ombudsman staff and volunteers.  The MFCUs are also required to review "
complaints alleging abuse or neglect of 
patients in health care facilties receiving payments under the State Medicaid plan. 
If the initial review indicates substantial potential for criminal prosecution, the unit 
shall investigate the complaint or refer it to an appropriate criminal investigative or 
prosecutive authority" (Social Security Act, section 1903(q)). At the time of this 
inspection, there were MFCUs in 38 States. Those States without a MFCU have 
Aagetnctieso wirth npareallyel  resGpoensinbilietiesr foar inlve)sti.ga tion
  of fraud and abuse (e.g., State
SCOPE AND METHODOLOGY 
At this time, there is no uniform definition of abuse among the States or researchers. 
The term abuse may cover many problem areas for nursing home residents ranging 
from environmental conditions needing correction to actual mistreatment of residents. 
For purposes of this inspection, abuse is defined as mistreatment or neglect of 
nursing home residents and encompasses seven categories of abuse, excluding 
environmental and financial issues. These seven categories were defined using simple 
definitions (figure 3) based on a review of the literature related to abuse (appendix 
F). 
Since natinal abuse statistics are not available and States vary in how they define abuse 
and collect statitics, we decided to survey knowledgeable inividuals involved directly or 
Specifically, the inspection relied on 232 intervews 
indirectly with nursing home care. 

with respondents representing State, national, and Federal organizations which are 
either 1) involved with receiving, investigating, and/or resolving abuse complaints 
involving nursing home residents, or 2) knowledgeable and concerned about nursing 
home or elder issues (e.g., State oversight agencies for nursing homes or advocates of 
the elderly or nursing homes). (See appendix A and figure 4 for summary 
information on respondents sampled.) . These individuals were identified through 
contacts with the regional HCFA offices as well as several State agencies (e.g., State 
Ombudsman and single State agency for Medicaid). 
A minimum of three principal entities were interviewed in each of 35 States: 1) State 
Ombudsman, 2) investigator or director of the State MFCU, or legal counterpart 
where no MFCU exists, and 3) State nursing home complaint coordinator (the 
nursing home administrators' primary contact for abuse complaints). These entities 
were selected because our pre inspection indicated they were the most often involved 
in nursing home abuse complaint receipt and resolution in most States. 
In 8 of the 
35 States, we intervewed additional individuals including nursing home 
administrators, nursing home and resident advocates, and medical professional 
licensure personnel. Figure 4 shows the 35 States from which respondents were 
selected.  Participants, based on their practical 
expertise and knowledge, answered a wide 
range of questions, by telephone or in-person intervews, concerning different aspects
of abuse in nursing homes including the prevalence and 
severity of the seven abuse
categories. While the experiences and perceptions of the 
participants provide the
basis for the findings and 
recommendations of this report
, these findings appear
consistent with the information and 
statistics available from the States and 
independent researchers.  INSPECTION ABUSE DEFINITIONS 
ABUSE: Mistreatment or neglect of nursing home residents. 
Physical Abuse

Infliction of physical pain or injury.

Examples include individuals either 1) reacting inappropriately to a situation, such as pushing or slapping a resident 
or 2) intentionally doing bodily harm. 
Misuse of Restraints 
Chemical or physical control of a resident beyond physician s orders or not in 
accordance with accepted medical practice. 
Examples include staff failng to loosen the restraints within adequate time frames or attempting to cope with a 
resident' s behavior by inappropriate use of drugs. 
Verbal/Emotional Abuse

3. 
Infliction of mental/emotional suffering.

Examples include demeaning statements, harassment, threats, humilation or intimidation of the resident. 
Physical Nealect 
Disregard for necessities of daily living. 
Examples include failure to provide necessary food, clothing, clean linens or daily care of the resident's necessities 
(e.  , brushing a resident's hair, helping with a resident's bath). 
Medical Nealect

Lack of care for existing medical problems. 
Examples include ignoring a necessary special diet, not calling a physician when necessary, not being aware of the 
possible negative effects of medications, or not taking action on medical problems. 
Verbal Emotional Ne lect

6. 
Creating situations in which esteem is not fostered.

Examples include not considering a resident's wishes, restricting contact with family, friends or other residents, or
more simply, ignoring the residents' need for verbal and emotional contact. 
Personal Propert Abuse (  Goods) 
Illegal or improper use of a resident'
s propert by another for personal gain. 
Examples include the theft of a resident's private television, false teeth, clothing or jewelry. 
FIGURE 3
 "..
RESPONDENT SAMPLE

* Statu 
Vlalted On81te 
SURVEY RESPONDENTS BY ROLE

Type of Respondent  Number  % of All 
Respondent 
State 
Complaint
Coordina tor  16% 
35 States Contacted  Survey and Certification
Surveyors 
Alabama Louisiana  New Mexico MFCUs Or Counterpart 
Alaska Maryland New York 18% 
Arkansas  Massachusetts  North Dakota * Professional Medical 
California  Michigan Ohio Licensure Boards 
Colorado Minnesota  Oklahoma *
Connecticut  Mississippi Pennsylvania Ombudsman  16% 
Florida  Missouri * South Carolina * Resident Advocacy
Georgia Montana * Texas Organizations 
Idaho *  Nebraska * Washington
Indiana  Nevada * Wisconsin Nursing Home
Illnois New Hampshire Wyoming * Industry  13% 
Kansas *  New .Jersey 
National Organizations 
. States with no Medicaid Fraud Control Unit 
Consumer. Industry and
Local Law Enforcement 
Federal 
HCFA 
OIG 
FIGURE 4
 .... 
.'.'.'...... .". .............. ..... .,... ..   ..~~ ". .... . ..".~~,.". .,". ..~~ '".,.'.."..." ,"~.~...,.".  .. ". . "...', ...'.. . ...."..'. ....,,.. . " ,"."""..." .....,'' ."..,. ,".. . ..,...       ".'"",..." ,.......,. ..... ... ........ .  ......... .  ................ ..........  .......... .... .  ........  .. ............. ...... .... ..... .................  ......  "....... ....... ...  .. '........ .......... ...... . .....'   .. .......... .....................~ .. .. ....... .~... ....... ..~.  .. .' ....~." ...".. ...~... .' . "..,....". ..... ...." ,.,,.. "".".',.
FINDINGS 
Near  resoo 
a prob  nursinQ homes. 
all  cae  abuse is
In each of the seven abuse categories defined for this study, 95 percent or more of 
the respondents indicate abuse is a problem for nursing home residents. 
Additionally, for every abuse category, more respondents believe it is worsening 
rather than improving. Respondent perceptions of increasing abuse appear to be 
supported by statistics from several States. Eleven States responded 
to our request 
for abuse reports and/or complaints which occurred during 1987 and 1988 or 1988 
and 1989. Eight States reported increased abuse statistics, while two reported no 
increase, and only one reported a decrease. 
'" n. ...."... 
Perceht. Chaljg  P8rted,il?q 
. .. n.

ill 
:Zj........................

..M 
$hiQQtgQ..
S6lih  afqnQ 
Old  h6hia,/..... 
Mi9hi9?h 
Neyad.i(t( 
NewVotk\ 
or reports of abuse 
These States reported receipt of  331 complaints 
 during 1988. 
Respondent difer. however. reQardinQ the severi of the problem. A maiori of 
Ste  aQees 
the  oversiQht  and resident advoces for nursinQ homes perceive 
indust 
serious problem. while many nursinQ home administators and 
abuse  as a 
represntes percee th problem as minor.

Although an of the seven categories of abuse are seen as problems for residents 
respondents perceive varyng degrees of severity (major, moderate, minor) for each 
category. Figure 5 shows these varyng respondent perceptions as to problem 
severity. There is relative consistency among four main respondent types (State 
Oversight agencies and resident advocates - MFCU, Survey and Certification  .: 
Complaint Coordinator and Ombudsman) while the nursing home industry 
respondents consistently report lower problem 
severity. Differences between the
respondent views on problem severity may be the result of 1) 
job function, 2) more
direct versus indirect contact with the residents or the provider 
community, or
3) more knowledge or understanding of the problems. See appendix B for further
respondent perceptions concerning the seven abuse 
categories. 
NURSING HOME INDUSTRY RESPONDENTS LESS OFTEN PERCEIVE ABUSE

AS A SERIOUS PROBLEM THAN DO OTHER RESPONDENT TYPES

ABUSE CATEGORY 
(! PHYSICAL ABUSf

Wil
0.0 (g MISUSE OF RESTRAINTB
?-o
f- 2 VfRBAL/fMOTIONAL ABUSE
f- --
PHYBICAL NEGLECT

0:(
IIIDICAL NfGLfCT
o W  l! VERBAL/EMOTIONAL NEGLECT

U0. .):  -
 lZ PERBONAL PROPfRlY ABUSf
il(/ 0
a: 
oLL( W/  0. RESPONDENT TYPE
f-
il .:  STATf MfDICAID PRAUD

CONTROL UNIT (MFCU)
U CD

ff  BTATf SURVfY AHD 
0. I- CERTIFICATION UNIT

STATf COMPLAINT COORDINATOR

STATE OMBUDSMAN

NURSING HOME INDUSTRY 
(NURINO HOME ADMINIBTRATORS
AHD INDUSTRV ADVOCATES)
ABUSE CATEGORY 
FIGURE 5 
As is the case with perceptions of the 
severity of abuse categories, nursing home
industry respondents often have a different view of the trend of abuse 
categories 
than do other tyes of respondents. As figure 6 shows, nursing home industry
respondents tyically 
perceive physical abuse, physical neglect, misuse of restraints
and medical neglect as improving or 
staying the same. 
On the other hand, State Ombudsmen and complaint coordinators tyically see 
these
problems as worsening or staying the same for nursing home 
residents. An average
of 49 percent of complaint coordinators and 41 percent of State Ombudsmen 
believe
resident abuse problems are worsening. In contrast
, 20 percent of the nursing home
industry respondents see abuse problems as worsening.  ::' 
RESPONDENT PERCEPTIONS OF ABUSE TRENDS:

IS ABUSE IMPROVING, STAYING THE SAME OR GETTING WORSE

FOR NURSING HOME RESIDENTS?

PHYSICAL  MISUSE OF  VERBAL/EMOTIONAL 
ABUSE  RESTRAINTS  ABUSE 
46%  48'1 
19% 
11".1 
30% 27% 26'1 
39'1 
49%
 54% 39% 37%  54% 473%8% 44%

PHYSICAL  MEDICAL  VERBAL/EMOTIONAL  PERSONAL PROPERTY
NEGLECT  NEGLECT  NEGLECT  ABUSE 
43'1 
21% 
32%  32% 
42%40%  39'1 3B% 
44% 50'1 
54% 56% 
KEY 
PERCENT OF 
RESPONDENTS 
TYPES OF RESPONDENTS 
SA VING 
" ABUSE IS IMPROVING 
eOI/PLAINT COORD. 
(STATE)  (UPPER BARS) 
ST ATE Ol/BUDSI/AN 
ALL RESPONDENTS  ABUSE IS STAYING 
THE SAME 
STATE SURVEYOR 
(MIDDLE BAR) 
STATE I/FeU 
ABUSE IS WORSENING 
NH INDUSTRY  \l 
(LOWER BARS) 
FIGURE 6
 Physical nealec. verbal and emoti 
or emot.Q 
ec. and verbal  abuse are
perceived as the most Dreva  orms of abuse. 
To gain an indication of the order of 
occurrence of the seven abuse problems
respondents were asked to rank the abuse 
categories in order of prevalence. 
Figure
7 arrays the median ranks according to 
prevalence. The problems at each 
level were
ranked about equal (no 
discernible difference based on the median) 
in frequency by
respondents. Because prevalence is 
. a factor in assessing the severity of a problem
(major, moderate, minor, or no problem), the most prevalent problems are often
believed to be the most serious for 
residents. 
RESPONDENT PERCEPTIONS OF RELATIVE 
PREVALENCE OF ABUSE CATEGORIES 
NURSING HOME INDUSTRY RESPONDENTS 
AGREE WITH THE RANKING ABOVE 
EXCEPT FOR PHYSICAL NEGLECT 
SOURCE: RESPONDENTS FROM  AND PROPERTY ABUSE. PROPERTY

ON81TE 8T A TE8  APBHUYSSEI CISA AL  LNEEVGELLE CI TP RISO ABL LEEMV EWLH 3IL E
PROBLEM. 
FIGURE 7  ...'..'...'..'..'.......  ..."...... .."..."........~ ... .....-.....,....,...~"....'. .. .. .. ........ ...~..,...."...-...  ..........'. ..."..................  .......,."... .....",.... .......... .. .. ...... .. ....  .. "...."., .,.  ...,.....  ."... ....,. .',.............. . .... .."...... ..........'. ." ......,... ,...",...,"  ....." ..................... .................... ....................  .......,." " . ," ,." ..... . ...'
. ~."... ,....,.~.'.."...,..~,.. ,..,   ..",". , ..'".......'...".. .. .'.......   "...."..."..."."., ."........ ..... ...,. .  . ..,.'...'.'.. ..'.'...'.....'...' . ". ''.  '..".''
Since State nursing home abuse reporting laws tyically separate resident abuse into 
the broad categories of physical abuse and neglect of care, many State agencies 
designated to receive and investigate complaints were not able to provide 
statistics 
according to the specific abuse definitions used for this 
study. Five States provided 
statistics of reports/complaints based upon the broad categories of physical abuse and 
neglect. Three of the five  was the most common abuse 
States report neglect 
reported in 1988 while two States report physical abuse as the most often reported. 
The percentage by State and tye of abuse is as follows: 
... ..... ... .. ... ..... .. n 
rcent  rceht  dse 
. n. .... .. 
Miont36  17%/ 
M;:achlisetts.. 
NeW'((jrk 
9?%L 
Kansas)... 
Nursing home staf. medica personnel. other paent and familv or visitors all 
contbute to abuse. However. aides and orderlies are the primary abusers for all 
abus 
caegories of 
except medical nealec. 
Nurse aides and orderlies have the principal responsibilty for the daily care of 
nursing home residents. As the primary caregiver to nursing home residents, it is not 
surprising most respondents, regardless of the  , say nursing home 
tye of respondent
staff (specifically, direct care staff - aides and orderlies) are responsible for most 
incidents of abuse except medical neglect. As seen in figure 8, a significant number 
of respondents believe medical personnel also
, other patients and family  or visitors 

may be primary abusers of nursing home residents in one or more categories of 
abuse.  PRIMARY ABUSER OF NURSING HOME RESIDENTS

ACCORDING TO RESPONDENTS

ABUSER  NUHROSMINEG    MEDICAL  OTHER  FAMILY OR 
II PROBLEM  STAFF  PERSONNEL  PATIENTS  VISITORS  NURSING 
HOME 
STAFF 
PHYSICAL ABUSE 
3 %  17 %  3 % 
ALL STAFF 
EXCLUDING 
MRIESSUTSREA IONFT S  (56 o/  48 %  1 %  2 %  ANRDN S.D OLC TVNOSR S 
AVBEURBSEA L/EMOTIONAL 7 %  13 %  10 % 
PHYSICAL NEGLECT  88  15 %  0 %  3 %  MEDICAL 
PERSONNEL 
MEDICAL NEGLECT  25 %  (0  1 %  3 %  LICENSED 
NURSES AND 
PHYSICIANS 
VERBAL/EMOTIONAL
NEGLECT  84 %  6 %  2 %  21 % 
PERSONAL PROPERTY 
ABUSE  1 %  18 %  15 % 
RESPONDENTS = 206 
ABUSER OF NURSING HOME RESIDENTS 
OPRIMARY 
TOT AL PERCENT MAY EXCEED 100 PERCENT AS SOME RESPONDENTS 
GAVE MORE THAN ONE PRIMARY ABUSER IN A CATEGORY. 
Graph Interpretation: For example, in the case of physical abuse, 89 percent of respondents 
reported that nursing home staff are the primary abusers of nursing home 
residents. 
FIGURE 8 
As indicated in figure 9, statistics from New York clearly support the 
finding that 
most nursing home abuse complaints can be attributed to nursing home aides and 
orderlies.  !!.===:"',-.  .. .:;.:.-..:..';.:'..::.''. .-- . -...-.-- 
Charges of Abuse by Title of Accused 
New York's Experience for 1988 
Title of Accused 
20  Number of Charge 
Nurse Aide/Orderly  w ::"E :0f:'  7':'  595  1 . 
Substantiated 
962 
Charges 
442 
Physician 
Other Non-licensed. 2
b 1

Administrator 6

Other f:f 
Family 
200  400  600  800 100 1200 1400 
Number of Charges 
Reports from the State Department of 
Health

Bureau of Longterm Care Services

FIGURE 9 
Respondent believe nursing home staff lack training to handle some stessl 
sitatons. 
Many factors contribute to the potential abuse of nursing home residents by staff. 
Figure 10 summarizes some of the factors which respondents believe contribute to 
abuse. 
Direct care nursing home staff frequently must cope with stressful situations. Many 
respondents indicate staff are inadequately trained to deal with the physical 
emotional, and psychological aspects of caring for the elderly and disabled. This may
result in abuse as an immediate response to a stressful or confrontational situation.  MANY FACTORS CONTRIBUTE TO ABUSE 
BY NURSING HOME STAFF

Low Staff 
Ra tios 
High Inadequa te
Stress  Supervision 
of Staff 
Lack of 
Lack of 
Skills  Empa thy 
Training 
for Elderly 
Cultural  Staff 
Differences  Personal 
Problems 
More 
High Staff
Severely
Turnover 
"' Residents 
Job 
Frustr a tion  Low Wages 
Abusive or 
Belligerent
Patient 
SOURCE: SURVEY RESPONDENTS 
FIGURE  ..............................................................................................................
.. 
. . . . . . . . . . . . . . . . . . . . . . . . . . .
..  ,..   .."  ..  ..  ..  ..  ..  .. ..  ..  . . . . . . . . . . . . . . . . . . . . . . . . . . .
As one respondent states  Faced with heavier levels of care, such as residents with 
more debiltating diseases, frustrated staff take out their 
stress on the residents. 
Respondents believe staff training deficiencies include a lack of sufficient training in 
1) behavioral skills to cope with or defuse confrontational situations
, and 2) stress 
management skills. Further, some respondents believe some staff lack empathy for 
the elderly because they lack the knowledge needed to understand problems of the 
elderly (e.g., Alzheimer 
s disease). 
Respondents cited many reasons for nursing home staff stress. Many respondents 
believe stress is caused by the reported increase in nursing home admissions of 
severely iI residents. This stress is related to the difficulties of caring for impaired 
and dependent residents who require help in many of the activities of daily living. 
According to the Senate Special Committee on Aging (figure 11), as many as 63 
percent of nursing home residents suffer disorientation or memory impairment, with 
47 percent suffering senilty or chronic organic brain syndrome. 
SELREEOTSEI DD EONHTASRA 8O5T ER I ST I os OF NURS I NgOSS H)O  ME
YEARS AND OLDER  (1 
Characteristic 
Percent
Affected 
Se x: 
Ma Ie  25.
F ema Ie  74.

Patient  Requires Help:

BDart ehsi sni 9n g. .................................... 91 .

77.
Gseint t9i nTgo i let Room 63.
In and Out of Bed ...................  62.

Eat I ng 
40.

Difficulty With Bowel and/or Bladder Control  54.

Disorientation 
or Memory Impairment .................. 62.

Senile or Chronic Organic Brain Syndrome ....  47. 
SOURCE:  Panrgeid n p Aag r d meA  mIde   nbr   1yIs  tc Sr  aae  tn(  1aI t9oe n8   0S7   -np 8  e  8Ac  geI  I d  anI   I9t   CIo onm)m
  I t tee

FIGURE 11 
Other factors which may add to the stress encountered by nursing home staff and 
residents include cultural differences between staff and residents, personal problems 
of staff or residents, and abusive or bellgerent residents.  Most respondents believe staff certifcation and traininQ will help to deter resident 
abuse. 
The required content, format and duration of training vary widely among States, with 
most training concentrating on health and safety precautions (e.  , lifting a resident 
fire prevention, evacuation procedures, sanitation). Most respondents cite the value 
of staff certification and training. 
Of all respondent types, the nursing home industry respondents (47 percent) were 
the least likely to report that training and certification would deter abuse. Reasons 
cited include: 1) present training and certification have not effectively deterred 
abuse; 2) training does not usually include stress management; 3) overwork resulting 
from understaffng is not affected; 4) inadequate salaries for hiring qualified 
personnel wiI not change; and 5) lack of professional supervsion is not corrected by 
existing certification. 
Administrative or manaQement factors also contribute to nursing home resident 
abuse (e.Q., inadeQuate superv  turnover, low staf to 
staff. 
resident ratios). 
Inadequate supervision of staff, low staff to resident ratios, high staff turnover, and 
low wages are cited by some respondents as factors contributing to abuse of nursing 
home residents. As discussed previously, nurse aides spend more time providing 
residents necessary direct care than any other group of nursing home personnel. 
However, this group of employees has the highest rate of turnover, averaging 75 
percent annually, according to one study by Almquist and Bates (1980). Low wages 
and the absence of employee benefits, recognition, and opportunities for 
advancement may all contribute to job dissatisfaction and rapid turnover among 
nurse aides. 
Nurses experience many of the same problems confronting nurse aides. Additionally, 
nurses have an increasingly important role of supervising and training 
paraprofessional staff. Respondents, recognizing the nurses' problems in meeting. 
these responsibilities, say inadequate supervision of direct care staff contributes to 
abuse. Although responsible for much of the training and supervision of direct care 
staff, nurses often lack training to adequately perform these functions. The 1985 
Invitational Conference on Issues and Strategies in Geriatric Education noted 
deficiencies in nurse supervising and teaching skiIs, and indicated nurse education 
programs do not routinely offer training in these areas. Compounding these 
problems are the numerous responsibilties nurses have in other areas (e. 
administrative paperwork). 
In some homes, the ratio of nurses to nurse aides may be inadequate, just as the 
ratio of nurse aides to residents may be inadequate. In order to meet State or  Federal facilty staffing requirements and to quickly fiI vacancy positions which may 
result from high turnover rates, many nursing home administrators have chosen to 
use temporary servces. Some respondents believe use of such servces (nurse and 
nurse aide pools) may be on the rise. Although temporary employees can fiI critical 
staff shortages, several respondents expressed concern that temporary employees may 
not have been adequately screened or trained to care for nursing home residents. 
RECOMMENDATIONS 
Because this inspection indicates abuse may be a problem for nursing home 
residents, we recommend the following: 
The Health Care Financing Administration (HCF A) should: 
Require, as part of its nurse aide training regulations, ongoing 
training concerning the aging process and mechanisms to cope with 
and avoid confrontational situations. Further, nursing homes should 
be required to document staff training and understanding of abuse 
and reporting responsibilities and procedures for abuse incidents. 
Require, as part of the admission requirements for a new resident 
nursing homes to inform residents about differences between living 
in a nursing home environment vs. living at home, possible problems 
they rimy encounter, and ways to deal with such problems. 
Require, as part of its conditions of participation for nursing homes 
supervsory and training staff to acquire skiIs necessary to effectively 
train and supervise paraprofessional and nonprofessional staff. 
The HCF A should further support research 
concerning long term care 
policies which promote staff stabilty and provide for adequate staff-to
resident ratios necessary to control stress and abuse. 
The Administration on Aging (AoA) should collect and disseminate 
information about nursing home practices which avoid stress and abuse 
and promote staff stabilty and adequate supervsion.  DEPARTMENTAL COMMENTS

Comments were received from the Assistant 
Secretary for Planning and Evaluation 
the Office of Human Development Services, the Administration on Aging, and the
Health Care Financing Administration. (See appendix D for the 
full texts. 
Assistat Sereta 
for Planning and 
Evaluation (ASPE) 
The ASPE agreed with the findings and recommendations of the report. More 
specifically, it "supports the OIG's recommendations for improved training of nurses 
aides and orderlies about how to cope with 
stressful situations and resident behaviors 
without resorting to abuse. 
Ofce  of  Human Deelopment Services (OHDS) 
The OHDS concurred with the report. 
Administrtion on Aging (AoA)

The AoA agreed with the findings and recommendations of the report. 
Healt Cae 
Financing Administrtion (HCFA) 
While the HCF A generally agreed with the report, it did have concerns with the 
primary data gathering technique utilzed
, an opinion 
, that is survey rather than a 
scientifically controlled review, which resulted in opinion data "presented as fact."
The HCF A also felt it would be advisable to include more information about the 
intervews and information gathering processes used in the study. 
Additinal infonnatin has been provided in the Scope and Methodology sectin of the 
report. Although evaluatin stuies do not produce absolutely certain infonnatin
, they
can provide relatively objective data. As the report indicated, there was little relevant 
statitical or applicable published research data concerning abuse in a nursing home. 
We started with an assumptin that inividuals who routinely receive complaints of 
abuse, survey for inicators of abuse, investigate abuse, or resolve abuse incidents are 
knowledgeable sources.  The  survey method was designed to provide descriptive 
infonnatin of extig processes using statements of opinion from a 
representative
populatin. 
Findings and recommendatins related to the survey (to identify whether
abuse was a problem, to what extent, etc.) were a result of both content and qualitative  analyses of the survey responses, available State statistis and legilatin/regulatin, and 
available research. We recognize the information provided by the respondents is 
signifcant only in the way it is regarded by the researcher or the 
readers. There is no 
absolute interpretatin of the informatin provided. 
GeneraIIy, the HCF A agreed with the recommendations of the report. The HCF A 
believes their implementation of the applicable statutory requirements of the 
Omnibus Reconcilation Act (OBRA) of 1989 and the Social Security Act will fulfil 
the recommendations of this report. In meeting a portion of the legislative 
requirements, the HCF A 
has revised the conditions of participation for nursing 
homes (effective October 1, 199). The HCFA believes the revised requirements will 
contain many of the safeguards recommended by the OIG. 
The HCF A inicates many of the recommendations will be met by the new regulatins. 
We agree that draft regulations issued thus far represent a substantial improvement over 
regulatins now in effect. However, some of these regulatins are still in the public 
review and comment stage and may change. Even more importantly, the regulations 
defer to State law on the critical issues of complaint reportng, investigating, and follow-
up. Hence, their impact will depend greatly on how aggessively the States move on
these problems. Similarly, nursing homes wil have to comply with the State law. We 
will, therefore, defer any assessment of whether our recommendations have been 
implemented until the new regulatory requirements are in place and States and nursing 
homes have made at least  implement them. 
initil efforts to  APPENDICES
  APPENDIX A

NATIONAL ORGANIZATION RESPONDENTS 
American Association of Homes for the Aging 
1129 20th Street, NW 
Washington, D. C. 20036 
American Association of Retired Persons - Central Office 
Criminal Justice Servces 
1909 K Street, NW 
Washington, D. C. 20049 
American Health Care Association 
1201 L Street, NW 
Washington, D. C. 2005 
American Medical Directors Association 
12100 Blue Paper Way 
Columbia, Maryland 21044 
National Aging Resource Center on Elder Abuse 
Research and Demonstration Department 
810 First Street, NE 
Washington, D. C. 2002-4205 
National Association of Attorneys General 
444 N. Capitol Street, Suite 403 
Washington, D. C. 20001 
National Association of Chiefs of Police 
Street 
1100 NE  12S 
Miami, Florida 33161 
National Association of State Units on Aging 
2033 K Street, NW, Suite 304 
200 
Washington, DC 
National Citizen s Coalition for Nursing Home Reform 
1424 16th Street, NW 
Washington, D. C. 20036  National Sheriffs Association

1450 Duke Street 
Alexandria, Virginia 22150 
Police Executive Research Forum 
2300 M Street, NW, Suite 910 
Washington, D. C. 20037 
Police Foundation 
1001 22nd Street, NW Suite 200 
Washington, D. C. 20037 
Rehabilitation Care Consultants
, Inc. 
6401 Odara Road 
Madison, Wisconsin 53719  APPENDIX B

Tables I-VII Present Respondent Perceptions on Abuse Categories as Problems 
Extent of the Problem, and Whether the Problem is Perceived as Worsening. 
Table I  Physical Abuse 
Table II
 Misuse of Restraints 
Table III
 VerballEmotional Abuse 
Table IV
 Physical Neglect 
Table V

Medical Neglect

Table VI
 VerballEmotional Neglect

Table VII
 Personal Property Abuse   .....-.-... -.. ......... -.. -......--. ........-.-.-.- -..-..-'.- ...
TABLE I

PHYSICAL ABUSE 
RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 
SEVERITY OF THE ABUSE 
FOR RESIDENTS 
100%  100% 
90%  90%  MAJOR 
PROBLEM 
80%  80% 
74% 
70%  70% 
"- I
MODERA TE 
I- W  60%  57%  60%  PROBLEM 
50% 
50%  50% 
a: (L  42% 
(L W  40%  38%38%  40% 
MINOR 
30%  30%  33%  25%  31%  30%  PROBLEM 
22% 
20%  17% 
11% 
10%  PROBLEM 
:: 0% 
STATE  ST A TE  ST ATE 
COMPLAINT  MFCU  SURVEY AND  MAJOR AND 
COORDINA TOR  CERTIFICA TION  MODER A TE 
COMBINED 
ABUSE TREND: 
IS IT GETTING WORSE. 
BETTER OR STAYING THE 
SAME FOR RESIDENTS 
100%  100% 
90% 
80% 
WORSENING 
70% 
"-I
59%  60%  60% 
I- W  I::::::::j 
49%  48%  50%  IMPROVING 
43% 
a: CL 
CLW  40%  39%  40% 
27%  30% 
26% 
STAYING 
20%  20%  THE SAME 
10%  10%  -_.... _._----
TABLE " 
MISUSE OF RESTRAINTS 
RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 
SEVERITY OF THE ABUSE 
FOR RESIDENTS 
100% 
100% 
90% 
90% 
MAJOR 
80%  PROBLEM 
80% 
70% 
LL (J  70% 
I- 60%  57%  56%  60%  MPORDOEBRLAE MTE  
ff(J  50%  46%  44%  44%  50% 
40%  36%  38%  40% 
32%  MINOR 
30%  27%  26% ::  30%  PROBLEM 
20%  18%  19%  : 19%  20% 
10%  10% 
PROBLEM 
MAJOR AND 
MODER A TE 
COMBINED 
ABUSE TREND: 
IS IT GETTING WORSE. 
BETTER OR STAYING THE 
SAME FOR RESIDENTS 
100%  00% 
90%  90% 
80%  80% 
WORSENING 
LL I 70%  70% 
I- W  60%  60% 
54%  53%  I::::q 
aw: (0/ 50%  48%  47%  48%  50%  IMPROVING 
O-W  40%  39%  40% 
34% 
30% 
30%  26%26%  27%  30% 
20%  20%  22%  20%  TSHTEA YSIANMGE  
14% 
10% 
ST ATE  ST A TE  STATE  STATE  STATE 
COMPLAINT  MFCU  SURVEY AND  OMBUDSMAN  NURSING HaM 
COORDINA TOR  CERTIFICA TION  INDUSTRY  ----..-..-..----.--. ... ...
T ABLE III 
VERBAL/EMOTIONAL ABUSE 
RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 
SEVERITY OF THE ABUSE 
FOR RESIDENTS

100%	 100% 
90%  90%  MAJOR 
PROBLEM 
80%  80% 
70%	 70% 
LL I- 54 % -..-..-..-.-. 
MODER A TE 
I- W  60%	 56%  60%  PROBLEM 
50%  50% 
a:Q	 45%  43%  43% 
4300%%   32%  31%  36%  33%  39%  4300%%   P1RM..O.I/NB OLRE M 
20%  21%  21%	 18%  20% 
14% 
10%	 10%  PROBLEM 
. 0%

ST A TE  ST A TE 
MFCU  SURVEY AND  MAJOR AND 
CERTIFICA TION  MODER A TE 
COMBINED 
ABUSE TREND:

IS IT GETTING WORSE. 
BETTER OR STAYING THE

SAME FOR RESIDENTS

100%	 00% 
90%	 90% 
80%  80% 
WORSENING 
71% 
70%  70% 
LL I-	 62% 
I- W	 60%  54%  53%  60%  I/)(j 
50%  50%  47%  50%  IMPROVING 
a:Q 44%

w(f 
40%  37%  40%

30%	 30% 
24% 
ST A YING 
20%  19% 19%  20%  THE SAME 
10%	 10% 
5T A TE  ST A TE  STATE  STATE  STATE 
COMPLAINT  MFCU  SURVEY AND  OMBUDSMAN  NURSING HOME 
COORDINA TOR  CERTIFICA TION  INDUSTRY  ,,- '_'-,' -"-" _'_" --" .-.- \.. .:::
TABLE IV 
PHYSICAL NEGLECT 
RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 
SEVERITY OF THE ABUSE 
FOR RESIDENTS 
100% 
100% 
90%  90% 
MAJOR 
80%  80%  PROBLEM 
u. f 70%  70% 
65% 
60%  57%  53%  60%  MPORDOEBRLAE MTE  
50%  47%  46%  50% 
a: CL 
CL W  40%  37%  40%  40%  1(,.,)' 
MINOR 
30%  27%  30%  PROBLEM 
20%  19%  13%  20% 
, 15% 
10%  10% 
PROBLEM 
STATE  STATE  STATE  ST A TE 
MFCU  SURVEY AND  OMBUDSMAN  NURSING HOME  MAJOR AND 
CERTIFICA TION  INDUSTRY  MODER A TE 
COMBINED 
ABUSE TREND: 
IS IT GETTING WORSE. 
BETTER OR STAYING THE 
SAME FOR RESIDENTS 
100%  100% 
90%  90% 
80% 
WORSENING 
70% 
LL f
61% 
54%  56%  60%  1.())1 
47%  50%  IMPROVING 
aw: (CjL 40%  43%43% 
CLW  40% 
34%  32%  33% 
30% 
STAYING 
20%  20%  THE SAME 
10%  10%  -.---. _.._....-- -..-- ...---.--....---..-... ...
T ABLE V 
MEDICAL NEGLECT 
RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 
SEVERITY OF THE ABUSE 
FOR RESIDENTS 
100%  100% 
90%  90%  MAJOR 
PROBLEM 
80%  80% 
e/ 70%  70% 
MODERA TE 
tf-;z  60%  57%  56%  54%  60%  PROBLEM 
50%  50% 
44% 
wCf  41%  I?:o\o:/:I 
CL  40%  40% 
32%  MINOR 
30%  27%  26%  30%  25%  27% .  30%  PROBLEM 
21% 
20%  13%  20% 
10%  . 6%  10%  PROBLEM 
ST A TE  ST A TE  STATE  ST ATE 
COMPLAINT  MFCU  OMBUDSMAN  NURSING HOME  MAJOR AND 
COORDINA TOR  INDUSTRY  MODERA TE 
COMBINED 
ABUSE TREND: 
IS IT GETTING WORSE. 
BETTER OR STAYING THE 
SAME FOR RESIDENTS 
100%  100% 
90%  90% 
80%  80% 
WORSENING 
70% 
u. f
61% 
f- W  54%  53%  56%  60% 
50%  50%  IMPROVING 
aw: eC/L 44% 
CL W  35%  40% 
32%  33% 
30%  28%  27%  30% 
22% :. 
20% O  STAYING 
20%  20%  THE SAME 
12%  12% 
10%  10% 
STATE  STATE  ST A TE  STATE  STATE 
COMPLAINT  MFCU  SURVEY AND  OMBUDSMAN  NURSING HOME 
COORDINA TOR  CERTIFICA TION  INDUSTRY  / "

.,,. 
'''' _''_''-'' --' ' ,,-,,,,:,-'
T ABLE VI 
VERBAL/EMOTIONAL NEGLECT 
RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 
SEVERITY OF THE ABUSE 
FOR RESIDENTS 
100% 
100% 
90% 
90%  MAJOR 
PROBLEM 
c.  80% 
70% 
70% 
ft-5z  60%  60%  MPaRDOEBRLAE MTE  
50%  50% 
44% "  44%44% 
UJ (/
Q.  40%  38%  39%  38% 38%  40%  I,,,,,,,, 
42%  MINOR 
23%  27%  19%  30%  PROBLEM 
20% 
10%  10% 
PROBLEM 
MAJOR AND 
MaDERA TE 
COMBINED 
ABUSE TREND: 
IS IT GETTING WORSE. 
BETTER OR STAYING THE 
SAME FOR RESIDENTS 
100%  100% 
90%  90% 
80%  80% 
WORSENING 
L1 f 70%  64%  63%  62%  70% 
f- UJ  60%  60% 
50%  50% 
a: Q. 50%  44%  50%  IMPROVING 
UJ (/ 41% 
Q. UJ  38%  40% 
32% 
30% 
STAYING 
20%  20%  THE SAME 
10%  10% 
ST A TE  ST A TE  STATE  ST ATE  STATE 
COMPLAINT  MFCU  SURVEY AND  OMBUDSMAN  NURSING HOME 
COORDINA TOR  CERTIFICA TION  INDUSTRY  _. - --". - ".' '
TABLE VII 
PERSONAL PROPERTY ABUSE 
RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 
SEVERITY OF THE ABUSE 
FOR RESIDENTS 
100%  100% 
90%  90%  MAJOR 
PROBLEM 
80%  - -.- h-n_n_..-u,,-.. - n_  80% 
oLL! zi f 70%  56%  70% 
MODERA TE 
if-jz  60%  53%  60%  PROBLEM 
50%  50% 
44% 
ffif  41%  L'o;:):,J 
40%  39%  38%  40% 
30%  33% ,:,'  32%  26%  34% "~c  30%  PRMOINBOLRE M 
21% 
20%  20% 
10%  10%  PROBLEM 
ST A TE  ST A TE 
OMBUDSMAN  NURSING HOME  MAJOR AND 
INDUSTRY  MODER A TE 
COMBINED 
ABUSE TREND: 
IS IT GETTING WORSE. 
BETTER OR STAYING THE 
SAME FOR RESIDENTS 
100%  00% 
90%  90% 
80%  79%  80% 
WORSENING 
70%  68%  69%  70% 
LL f-
f- W  60%  57%  56%  60% 
I"""",:"""", 
50%  50%  IMPROVING 
a: (L 
(LW  40%  40% 
30%  29%  30% 
25% 
21%  21% 21%  22%22%  ST A YING 
20%  20%  THE SAME 
10%  10% 
ST A TE  STATE  STATE  STATE  STATE 
COMPLAINT  MFCU  SURVEY AND  OMBUDSMAN  NURSING HOME 
COORDINA TOR  CERTIFICA TlON  INDUSTRY   APPENDIX C 
DEPARTMENTAL COMMENTS 
Comments on the draft reports were received from four Department of Health and 
Human Servces entities - the Assistant Secretary for Planning and Evaluation, the 
Health Care Financing Administration, the Office of Human Development Servces 
and the Administration on Aging. The full texts of their comments are attached.   DEPARTMENT OF HEALTH &. HUMAN SERVICES	 OHice of the Secretary 
""'''h1	 Washington , D, C, 20 
MEMORADUM  DEC 2 9 1989 
TO:	 Richard Kusserow 
Inspector General 
Arnold 
FROM:	 R. Tompkins 
Acting Ass 9tant Secretacy for Planning and Evaluation 
(1) "
SUBJECT:	 OIG Draft Reports:  Resident Abuse in Nursing 
Issues" and 
Homes: Respondent Perceptions of  (2) 
"Resident Abuse in Nursing Homes: Resolving Physical
Abuse Complaints 
I commend the OIG staff for producing two excellent reports 
it. 
documenting the problem of resident abuse in nursing homes and 
recommending strategies for dealing with  OASPE supports the 
OIG I S recommendations for improved training of nurses aides and 
orderlies about how to cope with stressful situations and 
resident b haviors without' resorting to abuse, improved abuse 
complaint investigation and resolution as part of state 
enforcement of Federal nursing home regulations , and improved 
systems for abuse reporting. 
In my view, these two reports merit the widest possible

dissemination among Federal and state agencies concerned with

nursing home regulation as well as among the nursing home

industry 'and consumer groups.   ---- _.'- --- -=--
--' - -  -_.
Health Care 
DEPARTME  T OF HEALTH So HUMAN SERVICES  Financing Administration 
-r--
Memorandum 
jJ.  44
Date  Los 
B, Hays 
From  Acir 
Rert:  Ab 
Drft  Reident  in Nuir Han: 
OIG  Rerrt Peion 
(1)  of Iss---06-88-00360,
Subject  Ab 
(2) Relvir Ibysica  C:lai---06-88-000361 
Inr
'le 
Office of the 
re  ca 
ya  st 
rerWrte. e F ir,  ditgo r  for  on th tw sujec
wgiethn  lyar agtro  twhere  Rteehr rr etw tiiPthoe yinoous' nl,  oafm mIe:strhs oh doasl otag.,l pd aHyi ccbueaerr ,ly
with  re,  done 
cu  maes.  stes we don uner the
to a  claist itohen  
Oc  be in effec tmtil
of paicipatirone,i wsh dl willr  e 
tht date,  th  whch cotain may 
1, 1990. On 
of  re ..,.  wil go 
by OIG in  aationa 
th safeg  wcd be aprqriate to ma 
effec. We do DX beieve it 
th t..

es at 
iWne ibeeiweve  airt  wcd be adisle to pinlrudo n oures in o:trhtio sn ta.b t 
tahpe p  pro  in  th 
gaintohnnteionr giatrhe rir  wa an opinoCn suIey , rather 
the data 
'sIci etnteifi caly  we prete as fact.
cotrlltehd  rreeitesWt. h fYoe ut ;t hie.  data  oter 
to proce  ab  am .
inesigate  see.  ioprcole m, whe thos
orfficeials reticr anu iI ha quion thi.t  is a  of th f 
retions 
QJ  whth on tha gsp  ific  yacr  aetatclhieeds.   Plea 
advis us  you  with ou poition at 
coenen.

Attclt
 Page 2

O:ts 
HCA 
We agree with ths reccllllendation an have be aci vel y p.rsing ths
end. As  th nue aide traing an cctecy 
regatiopnar t of  th  evaluation program
rrtianed in 1a,  Seretary is reqired to establish
regation for th qualification of intructrs of nuse aide traing
and cctency evaluation progcr. Whem we cia ot predict th preitshe e
cinonttreunct toofr st.h A floin rues, thre wil be  tht  qualificatirornt  for 
,s 4t2 fe r 483.30 inicates  facilities " have 
sufficient nutrhsi hngi gh  to provide nursing arnr rtealla,t e service to attain
or maintain  practicale 
physical,  an pschocial
well-being of each resident as determed  assessrt plan an
by resident 
hinadviivnigd uthal  ncaerce spalarn .s kilTsh tiso  wsuwpde rivnicsleu ddei rtehc  scuarrev isory Inras imnga esrtaff
llluding th  staf  in 
consistent with resident rights,  right to be free fran
ab.e . 
Recation No.

fur 
H:A shod conduct  research cocerng 
long term care P=licies
wrahtiicoh sp rncerctsea rsyt ftfo  sctoitlroitl ys traens sp raonv iadet ef.o r adeqate stf-patient
rr 
H:AO:ts 
We beieve tht we hae alreay develop . an appropriate  for 
enring tht wfacrirlietisees  haveR adeecqaattei oann a ppropriate staff. 
to  1c, H:A wil reqre tht 
metioned  in  suficient staff to 
facilities hhaCve er, it  provide for th nees of
residents,  ais tcele.a  tht increing stf-resident ratios
afalocnieli wtiiels  nmfota ucinot rfoleilx  inbility gTinh d ew.tet crmorgi ethn twea yrs ethre wmitl  pgirvoeisde
for staff staility an ene tht th 
nees an rights of reidents are 
tht  furtr  ths 
met. We alo note  any  area wod reqire
additional  research  in recs 
coition 
OIG  tht lChA,a a,s  part of its  of participation for 
shcud: 
hospi tals and nursing 
Reccration No.

al  ba 
Raelq sireu  Ern ursing  staabff ea nto h otshp intuar srinrigc bala  peardsornealt toor report
loc  enoinrccidaetn tas no ft o  resibility 
law  th cetral 
ahe calaits.
 agency assignEr 
for resolution of 
O:ts

lOA 
ths recation.  wil rere,

we 
We do not agree entirely with  ha), tht al
13 (for mrsing 
eaflefgeceidv ea hCXeo bbeer  r1e,p 1o99r0t ,t oat  t4h2  merrs i48n3g. ba adtrator or othr 
coition
accrdan with state law. lDA hospita 
official  in  th Joint Casion  Hethre 
participation satna ars  on Acreditation of 
Organzactiooni tion  do not reqire rerpertrieng  t.hoft a hheo.i tHac er, th
hospital  of participation do  follCM 
state law.  signficat abe  hoitals 
an  we ar not nawea re of a  coition poroblfan  paicinipation. 
dro enodot   nlo:ti elhv:eio etvihet taw .et  h OIGt ho ar evdiaser tcrura te a signficat problan with
to 
Recation No.

ha 
al abe  loc 
Reenqiorre cmarts,i ntgh   to reprt  riensidiebnitlsi t o  law

cetral agcy assigner 
ahe calaints an to th  an Certifictayti ofnor A resgol.u tion of
state SUrvey 
Ccts 
H:A 
fuy with ths tecmenatian. Aignaic, eeff ecive
WOe :dbo enort  agree  wil reqire tht al aleger  of ahe
reprt 1, 1990, we 
to  ba adrator 
th m.sing  or cutside official in 
aachcred ance with state law. we beiehvea ethrs  is suficient an tht tmhiotr 
incidents ca be effecively  by th aCstrator wi 
vart  enorcat 
th nee for invol  of law  personel. 
su 
Recdation No.

ha 
abe 
Raneq tihree  naucrtsiiongn  taen to tmha tnauirnsi nreg pboart.  of  incidents of 
by 
Cats 
H:A 
th  regation,  tht nuing
Wbe aag ree and l:ieve tht  new  which reqire 
condct investigation of aleger are, matain evidence of 
ahe is verifier, wil
investigationrse, aant tiaoe nco.r recive action whe 
satisfy ths  Page 2

Recation No. 
coct 
ire adstrators to  anysis of al incident reprt
determe imlication  acion. 
and appropriate 
O:ts

H:A 
regation  ths 
We agree an beieve tht th new  cover  issue.

Recardation No.

ha 
ire nursing  to spify, as pa of th nursing ha residents
plan of care, . abe of  eithr metaly
ua npllaen  to prevent  a reident who is 
or physicay  to prote hiherself. 
O:ts 
HCA 
an  tht th  regation cor ths 
Wree gagarteieo n  believe  new  c:rehive issue. The
at 42 CE 483. 20 provide for a  assessrt an
developrt of a plan of care for every resident. The plan assessrt an
plan of care shwd  spial 
include any  nesarers.i dent nees, inuding spific 
ahe, if 
steps for prevention of 
Recdation No.

ha 
su. 
ire nusing  to proide oogoin rrtoring an caeling
emloyee  of abing residents. 
O:ts 
IUA 
su 
th 
aticn. Coeling o:d 
We disagree with  eculIend be ineqate, an
of abe shadbe
we do not l:ieve tht person 
cotine to work with residents wher abeeindg  c:eltehd  . Theier bxetviioorn 
Itt be appropriate or th nu be  fran  job if 
are not net. 
oter Recations 
th recation  loc resibilities,
HCA agree with  for state an 
resolution an follCMp tht reires each state to natain retrievable
data for IDA. 
agr 
th  recation tht 
In addition, lCA also  with  joint  lCA 
ccn  and 
tahb eA dstraalt ion on Aging develop  defintion an categories of
for  state an Feeral reprting  wil  toard
ths  p.rpes. We  work 
end.  :::
Office of 
DEPARTMENT OF HEALTH &. HUMAN SERVICES	 ervices 
Human Development 
Assistant Secretary 
Washington DC 20201 
DEC 22 1989 
TO:	 Richard P. Kusserow 
Inspector General 
FROM:  Assistant Secretary 
for Human Development Services 
Draft Reports on 
SUBJECT:	 (1) "Resident Abuse in Nursing Homes: 
Respondent Perceptions of Issues, " OAI-06-88-00360 and 
(2) "Resident Abuse in Nursing Homes: Resolving

Physical Abuse Complaints, " OAI-06-88-00361

Thank you for the opportunity to review the draft reports on
Resident Abuse in Nursing Homes. We ,concur with the draft 
reports. 
If you have any questions, please contact Deborah Bass at

245-3176. 
/kL
Mary Sheila Ga
  DEPARTMENT OF HEALTH &. HUMAN SERVICES	 Off  of the Secretary 
Administration on Aging	 Washington, D,C. 20201 
JAN - 9 1990 
Richard P. Kusserow 
TO:	
Inspector General

FRO	 Acting Commissioner on Aging 
SUBJECT:	 Comments on the OIG Draft Reports on Resident 
Abuse in Nursing Homes 
The Administration on Aging (AOA) appreciates the 
Resident 
opportuni ty to comment on the OIG draft reports w
Abuse in Nursing Homes: Respondent Perceptions of Issues 

and wResident Abuse in Nursing Homes: Resolving physical
Abuse Complaints.  We are pleased that the current draft 
reports incorporate changes which respond to most of the 
concerns that AoA expressed about the earlier draft

materials. We want to thank George Grob for his time and

changes. 
diligence in making the necessary 
While most of our comments have been addressed, we continue 
to have serious concerns about one major item in the report 
The Executive 
on Resolving Physical Abuse Complaints. 
Summary (p. iii) under Recommendations relating to Federal
Responsibi  ities proposes, among other things, that the 
Administra tion on Aging should expand and strengthen its 
efforts to issue periodic public reports concerning abuse
trends. 
This topic. is discussed further on page 17 of the 
report which notes that, while the AoA Ombudsman Report is a 
major indicator of nursing home abuse, it cannot be used to 
obtain reliable national counts of abuse (particularly for 
specific problem areas.  The report goes on to state that, 
for several reasons which are cited (p. 18), there are no 
adequate national nursing home abuse statistics to provide 
an incidence rate or trend for nursing home abuse. 
We concur with the observation that there are no data which

can be used to provide an incidence rate or trend regarding

nursing home abuse. The impediments to the collection of

such data which the report cites are beyond the capaci ty of

AoA to overcome. Ther  fore, it is not possible for AoA to 
respond to the report' s recommendation to expand and

strengthen its efforts to issue periodic public reports

concerning abuse trends. In light of the report' s own

conclusions regarding the significant nature of impediments

to the collection of tren  data, we once again request that
 !"p

- 2

the recommendation concerning AoA which appears on 
p. iii

the Executi ve Summary delete any reference to issuance of

reports on abuse trends and be revised 
to read:

The Administration on Aging 
(AOA) should expand and

strengthen its efforts to 1) issue best practices for

preventing and dealing wi th resident abuse, 2) promote

public awareness and education concerning abuse occuring

in nursing homes and 3) promote use of volunteer

Ombudsman in nur sing homes.

Again, we appreciate the opportuni ty to review and comment 
on the draft reports prepared by OIG.  APPENDIX D 
PUBLIC COMMENTS 
Comments were received from several organizations with interests pertaining to the 
elderly, nursing homes, or law enforcement: 
American Association of Homes for the Aging 
American Health Care Association 
National Aging Resource Center on Elder Abuse 
National Association of Chiefs of Police 
National Association of Medicaid Fraud Control Units 
National Citizen s Coalition for Nursing Home Reform 
Police Executive Research Forum 
and local 
Additional comments were received from a select representation of State 
entities involved directly or indirectly with issues relating to the elderly, nursing 
homes, or law enforcement. AIl comments were reviewed and analyzed. Findings 
concerns 
and recommendations in both final reports reflect many of the pertinent 
and issues raised by the commentors on the draft reports. 
The following are short excerpts expressing concerns and observations of report 
reviewers: 
part report 
I am disturbed by the absence of national and state statistics in (the) two-
and (the) reliance on the impressions of a small sample of individuals with a skewed view 
am further disturbed by your failure to adequately define the term, 
of the issue. 1 
abuse " which has resulted in confused and unreliable findings." (Nursing Home

Advocate)

We must assist familes who have loved ones in a facilty to becme more aware of the 
aging procs and the circumstance surrounding the institution living. Consideration 
should also be given whereby training modules are made available to and participation in 
them encouraged for relatives and friends of the institutionalized aged and infirm. 
(State Complaint Cordinator) 
We feel strongly that your report should acknowledge the costs to the Medicaid and 
supervsors) training, as 
Medicare programs of such (supervisory training for direct care 
well as the time diverted from patient care activities to fulfll such requirements -
particularly at a time when there is a national shortge of skiled nursing personnel." 
(Nursing Home Advocte) 
feels strongly, and the final report of the National Commission on Nursing recgnize, 
that the Medicaid program -- through inadequate reimbursment --actually limits 
nursing home providers' abilty to recuit and retain adequate members of highly skilled 
nursing staff. We believe that HCFA, in approving State Medicaid reimbursement plans, 
must ensure that reimbursement rates allow nursing homes to compete with hospitals 
and other health care providers for scarce nursing staff." (Nursing Home Advocte)  I would like to see a study on the emotional 
makeup of the abusing aides to include
mental health exams and espeially depression 
scales since peple with mild mental
ilnesses get much worse under stress and may be impulsive or neglectful. To prevent
medical neglect I would like to see 
physician training in geriatrics and medical
directorship be much more widely required, and a strong medical director system in
nursing homes...  (Physician) 
The resistance to recmmendations of this nature 
(involving attitudes and understanding
behaviors) revolve around funding. 
At the risk of oversimplification, some of the
problems might better be addressed and 
resolved if there were not the present and near
impossible crazy quilt of 50 different State reimbursements for 
Medicaid. And there
might be far less medical neglect if Medicare did not discriminate against 
payments for
physician visits for patients in nursing homes.
" (Nursing Home Administrator) 
Require Medical Schools to offer courses in geriatrics
, and require rotation of interns in .
nursing homes; move toward nationalization of Medicaid payments.
" (Nursing Home 
Administrator)  APPENDIX E

BIBLIOGRAPHY 
A Consumer Prospective on Quality Care: The Residents ' Point of View  National 
Citizens' Coalition for Nursing Home Reform. 
Chance, Paul Attacking Elderly Abuse  Psychology Today. September, 1987. 
Committee on Nursing Home Regulation, Institute of Medicine  Improving the Quality 
of Care in Nursing Homes  National Academy Press: Washington, D.  , 1986.

Congress of the United States, Congressional Board of the 100th Congress  Losing A 
Milion Minds Office of Technology Assessment, Washington, DC: Government 
Printing Office, April, 1987. 
Dalton, Rex  State Effort to Close Hospital Points Up Industr Problems The San 
Diego Union, October 4, 1987. 
Dolon An Exploratory Stuy Comparing Atttues 
, Ronald and James E. Hendricks, 
and 
and Practies of Police Offcers and Social Service Providers in Elder Abuse 
Neglect Cases  Journal of Elder Abuse and Neglect, Volume 1  o. 1, 1989.

Doty, Pamel  and Ellen Wahl Sullvan  Community Involvement in Combating Abuse 
MiIbank Memorial Fund 
Neglect, and Mistreatment in Nursing Homes 
, Vol. 61, No. 
Ouarterly/Health and Society , 1983.

Douglass Domestic Mistreatment of the Elderly - Towards Prevention 
, Richard L., 
Prepared for the American Association of Retired Persons, Criminal Justice 
Servces, Washington, DC: 1987. 
Elder Abuse and Neglect: Recommendatins from the Research Conference on Elder

Abuse and Neglect  University of New Hampshire, June, 1986.

Fiegner, Janice J., Mark Fiegner, and Jack Meszaros  Policy Implicatins of a 
Statewide Survey on Elder Abuse  Journal of Elder Abuse and Neglect, Vol. 1, No. 
2, 1989.

Filnson, Rachel and Stanley R. Ingman  Elder Abuse Practice and Policy, Human 
Sciences Press, Inc., 1989.  Fleishman, Rachel and Revital Ronen 
Quality of Care and Maltreatment in the 
International Workshop on Stress, Conflct and Abuse in
Institutins of the Elderly, 

the Aging Family, Jerusalem
, August 25-
, 1986. 
Floyd, Jeanne 
Collecting Data on Abuse of the Elderly,
 Journal of Gerontological 
Nursing, Vol. 10, No. 12. 
Fredriksen, Karen I.  Adult Protective Services: Changes with the Introduction 
Mandatory Reporting, 
 Journal of Elder Abuse and Neglect, Vol. 1, No.  , 1989. 
Gaynes State Legilatin 
, Mindy,  Relating To Abuse And Neglect Of The Elderly, 
Informational Servce of the National 
Conference of State Legislatures, Denver
Colorado, Vol. 6, No.  , December
, 1981. 
Generations  Ouarterly Journal of the Western Gerontological Society, Vol. VIII 
No.  , Spring, 1984. 
Health Care Financing Administration  Health Care Financing Review, Volume 7
Number 3, Spring, 1986. 
Health Care Financing Administration  Program Statistics, Medicare and Medicaid 
Data Book
, 1988. 
Hudson, Margaret F.  Analyses of the Concepts of Elder Mistreatment: Abuse and 
Neglect  Journal of Elder Abuse and Neglect, Volume 1, No.  , 1989. 
Lefley, Harriet P.  Aging Parents as Caregivers of Mentally fll Adult Children: An 
Emergng Social Problem  Hospital and Community Psychiatry, Vol. 38, No. 10
October
, 1987. 
Lubahn Family Abuse of the Elderly: Theoris on the Absence of Federal 
, Kathry, 
Response: The Kingdon Model 
April 24, 1986. 
Medicare and Medicaid Patient and 
1444), One
Program Protection Act of  1987  (H.R. 
Hundredth Congress of the United States of America At the First Session
, January 
, 1987. 
Moroney, Helen  Abuse of the Elderly,
 The Daily Texan  November 26, 1985. 
Morrison, Malcolm H.  The Aging of the U.S. Population: Human Resource 
Implicatins  Monthly Labor Review, May, 1983.  National Council on the Aging, Inc.  Community Care Quarterly, Fourth Quarter 
1987, Vol. II, No. 
National Council of Senior Citizens, Legal Research and Servces for the Elderly, 
Washington
Elder Abuse and Neglect Reportng and Handling Legilatin 
, December 5, 1979. 
Nauman, Kate  Elder Abuse Laws: Problems of Comparions Between States  Field 
Seminar (SW687A), Spring, 1986. 
Malley, Terrence A., Everitt, Daniel E., O'Malley, Helen C. and Campion, Edward 
Mediated Abuse and Neglect of Elderly Persons 
Identifing and Preventing Family-
Annals of Internal Medicine (1983.007-000 American College of Physicians). 
Part I: Elder Abuse and Family violence in the Home: A Review of the Research 
(Excerpt), Elder Abuse and Neglect: A Guide for Practitioners and Policy Makers  San 
Francisco, CA., The National Paralegal Institute, February 1981. 
Pedrick-Cornell, Claire and Richard J. Gelles  Elder Abuse: The Status of Current 
Knowledge  Family Relations, July, 1982. 
PiIemer, Karl and David Finkelhor  The Prevalence of Elder Abuse: A Random 
The Gerontological Society of America, Volume 28, No.  , 1988.

Sample Survey 

PiIemer, Karl and David W. Moore Abuse of Patints in Nursing Homes: Findings 
From a Random Sample  University of New Hampshire, 1988. 
Survey of Staff, 
PiIemer, Karl and Denise Prescott  Psychological Effects of Elder Abuse: A Research 
Note  Journal of Elder Abuse and Neglect, Volume 1, No.  , 1989.

PiIemer, Karl A. and Rosalie S.  Elder Abuse: Conflct in the Family. Auburn 
Wolf, 
House Publishing Company, 1986. 
Plotkin, Martha R.  A Time for Dignity, Police Executive Research Forum, 1988. 
Quinn, Mary Joy and Susan K. Tomita  Elder Abuse and Neglect Causes. Diagnosis. 
and Intervention Strategies, Springer Publishing Company, Inc., 1986. 
Sabatino, Charles P.  CLE: Home Care Quality: Explorig the Unknown Part I 
Bifocal, Vol. 7, No. 3, Fall 1986.  Sabatino, Charles P.  CLE: Home Care 
Quality: Exploring the Unknown Part II
Bifocal, Vol. 7, No.  , Winter 1986. 
Salend, Elyse, Rosalie A. Kane, Maureen Satz, and Jon Pyoos  Elder Abuse 
Reporting: Limitatins of Statutes  The Gerontologist  Vol. 24, No.  , 1984. 
Select Committee on Aging, House of Representatives
, Ninety-Seventh Congress 
Physical and Financial Abuse of the Elderly,  San Francisco, Calif: U.S. Government 
Printing Office Washington, April 3
, 1981. 
Skolnick, Barbara and Pamela Warrick  The Right Place at The Right Time: A 
, 1985. 
Guide to Long-term Care Choices American Association of Retired Persons, Health
Advocacy Servces Program Department
Special Committee on Aging, United States Senate 
Aging America, 1987-1988 Ed. 
Special Committee on Aging, United States Senate  Information Requirements for
Evaluating the Impacts of Medicare Prospective 
Payment on Post-Hospital Long 
, 1985. 
Term-Care Services: Preliminary Report, (GAOIPEMD-85-8), Washington, D.C.: 
S. General Accounting Office, February 21
Special Committee on Aging, United States Senate 
Nursing Home Care: The 
Unfinished Agenda  May 21
, 1986. 
Subcommittee on Health and Long-Term Care of the Select Committee on Aging,
House of Representatives, Ninety-Ninth Congress Elder Abuse: A National Disgrace 
Washington, D.  , U.S. Government Printing Office
, 1985. 
Surgeon General's Workshop on Violence and Public Health 
Elder Abuse -
Evaluation/Treatment of Victims 
Preventin  October 27- , 1985. 
United States General Accounting Office, Report to the Chairman, Subcommittee on 
Intergovernmental Relations and Human Resources, Committee on Government 
Operations, House of Representatives  An Aging Society Meeting the Needs of the 
Elderly While Responding to Rising Federal Costs
, (GAOIHRD-86-135) September 
1986. 
United States General Accounting Office, Briefing Report to the Chairman 
Subcommittee on Health, Committee on Ways and Means, House of 
Quali 
Representatives  Medicare: Preliminary Strategies for Assessing  Care,
(GAOIPEMD-87-15BR) July, 1987.  United States General Accounting Office, Fact Sheet for the Chairman 
Subcommittee on Intergovernmental Relations and Human Resources, Committee 
on Government Operations, House of Representatives  Medicaid: Results of Certified 
Fraud Control Units, (GAOIHRD-87-12FS) October, 1986. 
United States General Accounting Office, Report to the Ranking Minority Member 
Special Committee on Aging, U.S. Senate  Medicare and Medicaid: Stronger 
Enforcement of Nursing Home Requirements Needed, (GAOIHRD-87-113) July, 
1987. 
United States General Accounting Office, Report to the Secretary of Health and 
Human Servces  Medicaid: Addressing the Needs of Mentally Retarded Nursing 
Home Residents  (GAOIHRD-87-77) April, 1987. 
Working with abused elders: assessment. 
Wolf, Rosalie S. and Karl A. PiIemer, 

advocacy. and intervention, University of Massachusetts Center on Aging, 1984. 
Wolf, Rosalie S., Karl PiIemer, and Michael A. Godkin  Elder Abuse and Neglect: 
Report from Three Model Projects, University of Massachusetts Center on Aging, 
1984.