June Gibbs Brown

Inspector General

Abuse Complaints of Nursing Home Patients

Nancy-Ann Min DeParle

Administrator

Health Care Financing Administration

Attached for your information is our report on abuse complaints involving nursing home

patients in selected States (OEI-06-98-00340).  Our original purpose in conducting this study

was to ascertain what can be learned about the extent and nature of abuse of nursing home

patients based on data available from the abuse complaint systems of 11 large States.  We used

this data in conjunction with data from other sources (such as survey deficiencies and

ombudsman complaints) to gain an understanding of conditions in nursing homes.  The results

were included in our report entitled, Quality of Care in Nursing Homes: An Overview.  That

report and our corresponding congressional testimony demonstrated the existence of serious

quality of care problems in some nursing homes. 

With regard to abuse complaints, we were able to obtain reliable data from only 8 of the 11

States we contacted.  We found that between 1 and 3 percent of their nursing home population

have registered a complaint.  One State indicates a much higher percentage of 17 percent. 

However, due to the lack of uniform data systems and definitions across States, we cannot

draw generalizations from those observations.  We also have no way of knowing whether

States with higher reported abuse complaint levels actually have more abuse occurring, have

more aggressive abuse reporting systems, or have some other outside influencing factors.

The data we obtained is about complaints made, but not necessarily substantiated.  Thus, we

cannot tell from the data to what extent nursing home patients are in jeopardy.  However, we

are able to see that what is being reported by patients is serious.  These complaints relate

directly to abuse and quality of patient care problems in an environment which should ensure

each patients well being.

We had planned to conduct a follow-up inspection on existing State patient abuse complaint

systems.  However, given the Health Care Financing Administrations (HCFA) plans to

strengthen the complaint process and its recent letter to the State survey agencies clarifying

HCFAs expectations for the collection, review, investigation, and reporting of complaints, we

do not believe an Office of Inspector General review would be useful at this time.  Instead, we 
 Page 2 - Nancy-Ann Min DeParle

will wait until the improved complaint process is implemented; we will then conduct an

evaluation of how the process is working.  We will work with your staff to develop the study

so that it will give them the feedback they need to ensure the new system takes hold

effectively.

In the meantime, we thought it might be useful for HCFA staff who are developing the new

system to have the benefit of our work to date on abuse complaints.  Thus, we are presenting

our findings in the attached report.  It provides more information on our attempts to obtain

State data as well as information we could glean from the State-provided data.  We hope that

interested HCFA staff and the research community will find it useful.

We are closing out this particular inspection.  There is no need for you to provide comments

on it.  However, if you have any questions please do not hesitate to call me or George Grob,

Deputy Inspector General for Evaluation and Inspections, or have your staff contact 

Mary Beth Clarke at (202) 619-2481. 

Attachment
 Abuse Complaints of Nursing Home Patients 
Department of Health and Human Services

Office of Inspector General

Office of Evaluation and Inspections

May 1999

OEI-06-98-00340
 Table of Contents

Introduction  1

Background  1

Difficulty Determining Abuse Frequency  2

Methodology  4

Individual State Results 
Abuse and neglect complaints from eight States  7

Abuse and neglect complaints as a percentage of 

two States nursing home populations  10

Endnotes  13

References  15

Appendices 
A - Request Letter to States

B - Examples of State Definitions of Abuse and Neglect

C - Analysis of State Specific Information

For further information, please contact Leah K. Bostick at 214-767-3310 or 1-800-848-8960.  Abuse Complaints of Nursing Home Patients 
Purpose 
To ascertain what can be learned about the extent and nature of abuse of nursing home patients 
based on data available from State abuse complaint data systems. 
Background 
Recent reports by the Health Care Financing Administration (HCFA) on nursing home 
responsibilities and processes, and General Accounting Office reviews of patient care in California 
nursing homes have raised serious concerns for patients care and well-being.  The Senate Special 
Committee on Aging held two hearings in the summer of 1998 on these results.  At the same time, 
the Office of Inspector General (OIG) undertook additional studies aimed at assessing the quality 
of care in nursing homes.  We recently issued reports on the inadequacy of criminal background 
checks for potential employees and raised questions about States responses to patient abuse. 
Future OIG reports will address a broad array of nursing home care issues, including a systematic 
review of all key provisions of the 1987 nursing home reform legislation and the Ombudsman role 
in nursing homes.  This report examines the extent of patient abuse in nursing homes as described 
in formal State abuse complaint reporting systems. 
Federal Laws and Regulations Regarding Abuse Complaints - The most important 
Congressional response to prior concerns for nursing home patients was the Omnibus Budget 
Reconciliation Act of 1987 (OBRA 1987).  This law assured and strengthened certain personal 
rights and protections for nursing home patients.  Personal rights include the right to not be 
physically or mentally abused, involuntarily secluded, and to be free from chemical and physical 
restraints.1  The guidelines for these regulations specify that a nursing homes responsibilities for 
preventing abuse also apply to practices and omissions which can lead to abuse, if left unchecked. 
Abuse, including neglect, can be inflicted by nursing home staff, visitors, or even other patients. 
The OBRA 1987 requires States to receive complaints and provide timely review and 
investigation of allegations of neglect, abuse, and misappropriation of resident property by any 
employee of the nursing home.2  New Federal regulations issued by HCFA, including enforcement 
regulations with new survey processes implemented in July 1995, were designed to help ensure 
those protections for patients.  The Older Americans Act (OAA) of 1965 and its subsequent 
amendments provide for State aging agencies to assess the need for elder abuse prevention 
services.3  A companion OIG report addresses the trend of abuse as reported by State 
Ombudsman offices.4 
State Laws and Regulations - All States have some form of legislation authorizing the 
protection of its vulnerable, incapacitated, or disabled adults in domestic settings (in the persons 
own home or that of a caregiver) by requiring reporting of abuse to either the States adult 
1
 protective services or through a State long-term care ombudsman.  While State statutes may not 
designate elder abuse, specifically, as a crime, most States do consider many forms of physical, 
sexual, and financial/material abuses of domestic elderly persons as crimes. 
Fewer States legislatively equally address abuse of these same individuals in institutional settings 
(nursing homes and other long-term care settings).  Most States have attempted to address this 
issue by legislatively mandating that physicians, nurses, and other health care professionals report 
suspected institutional abuse to a designated State office and requiring nursing homes to 
investigate, as well as report, any abuse occurrences in their facilities. 
Difficulty Determining Abuse Frequency 
Diversity of Government Agencies - Many Federal and State agencies are responsible for 
protecting elderly and disabled nursing home patients. 
At the Federal level, three Department of Health and Human Services (DHHS) agencies have 
either direct or indirect involvement with nursing homes and services to their patients: the 
Administration on Aging (AoA), HCFA, and the OIG.  The HCFA has ultimate responsibility for 
the Medicare and Medicaid programs, which includes ensuring that the reforms of OBRA 1987 
are implemented by States and nursing homes. 
In response to raised concerns, HCFA will add a new survey task requiring State surveyors to 
review each nursing homes abuse prevention plan aimed at preventing, identifying, and stopping 
physical or verbal abuse, neglect, and misappropriation of nursing home patients property.5,6 
However, sometimes the most glaring deficiencies and abuse incidences cited by surveyors against 
nursing homes are tagged as problems other than neglect or abuse, and rarely are deficiencies of 
nursing care, patients rights, or quality of care cross-tagged to neglect or abuse citations.7 
Consequently, State and Federal nursing home survey statistics probably do not accurately 
describe the incidence of abuse or neglect.  The HCFA also announced its support of additional 
nursing home reforms announced by the President in July 1998.  These reforms are directly 
related to abuse and neglect of patients, including the need to provide additional training to State 
nursing home surveyors in those States not adequately protecting nursing home patients from 
abuse.8 
At the State level, there are many public and private agencies and organizations concerned and 
actively involved in deterring institutional abuse.  These can include the State units on aging, law 
enforcement offices (police, attorney general), medical examiners offices, State long term care 
ombudsman offices, the State health department, and the agency responsible for licensing and 
certifying nursing homes.  Most typically, this latter State agency, which ensures nursing homes 
meet Medicare and Medicaid requirements, is also designated as the primary contact for State-
required institutional abuse reporting by physicians and other health care professionals.  The 
2
 variation in Federal and State agency requirements, processes, and definitions compounds the 
difficulty of obtaining a realistic national picture of nursing home abuse occurrences. 
Lack of Standardized Definitions - The AoA Annual State Ombudsman Report is the only 
current standardized means of collecting national abuse data.  This report uses the Older 
Americans Act and HCFA guidelines for capturing complaints broadly classified as abuse, gross 
neglect, or financial exploitation.9  In 1996, all States began submitting the report to AoA through 
its National Ombudsman Reporting System.  This new system captures more specific data 
elements than were previously reported.  Specifically, the categories for which AoA collects abuse 
or neglect information included physical abuse, sexual abuse, verbal/mental abuse, financial 
exploitation, gross neglect, and resident-to-resident physical or sexual abuse.  However, unless 
the State Ombudsman has been designated by State statute as the entity to which all incidents and 
complaints of nursing home abuse and neglect must be reported, the AoA report will identify only 
those issues or complaints brought to them by their own nursing home ombudsmen and aware 
citizens. 
Federal definitions first appeared in the 1987 Amendments to the Older Americans Act.10 
However, these definitions only provide guidelines for identifying problems; they are not 
intended or used for enforcement purposes.  These definitions have recently been expanded to 
include language specific to the HCFA Survey Forms and Interpretive Guidelines for the Long 
Term Care Survey Process, April 1992.11  As previously mentioned, in June 1995, HCFA 
released revised guidelines to Federal and State nursing home surveyors.  However, these 
guidelines continue to provide non-enforceable definitions relating to sections of the law reviewed 
for compliance (generally citation tag numbers F221 through F224). 
Ultimately, each State has the responsibility for protecting its older persons.  As such, States 
usually define abuse of elderly persons through their State laws.  However, these definitions vary 
between States regarding what constitutes abuse, neglect, or exploitation of an elderly individual. 
Defining abuse becomes even more difficult when adding the distinction of elderly and disabled 
in nursing homes versus domestic abuse (occurring in the community).  In most cases, State 
statutes provide the necessary definitions for the reporting abuse occurrences by nursing homes 
and other health professionals, again, with varying degrees of specificity.  Additionally, many 
researchers have coined their own unique definitions to study the problems of domestic and 
institutional abuse. 
Responsibility for Institutional Abuse Resolution - States are required to ensure receipt and 
timely review and investigation of allegations of neglect, abuse, and misappropriation of resident 
property by any employee of the nursing home.12  While many State agencies have some 
responsibility for resolving nursing home problems, each State usually designates to the nursing 
homes a coordinating entity (an individual or a particular State agency) with central State 
authority to receive complaints of mistreatment or neglect of nursing home patients.  Several 
different State agencies may be assigned responsibility for designing, operating, and coordinating 
nursing home complaint processes including the: 
3
 State Ombudsman under the direction of the State Agency on Aging,

Medicaid Fraud Control Unit (MFCU) or other legal authorities (State Office of the Attorney

General),

Agencies for nursing home certification and licensure,

Licensure agencies for medical personnel,

State adult protective services, and

Local or State law enforcement agencies.

However, while coordination for nursing home abuse complaints may be located in any number of 
State agencies, the responsibility usually is assigned to the State nursing home survey and 
certification agency.  In a few States, the State agency on aging, which houses the State 
Ombudsman Program (required by AoA), may have the primary responsibility for abuse or neglect 
complaints of nursing home patients. 
Available Research on Incidence - Although there are many studies available on domestic 
abuse, much less research has addressed institutional abuse.  This was recently reconfirmed by 
testimony of the Acting Principal Deputy Assistant Secretary for Aging, AoA, who stated that In 
spite of all the anecdotal information, media exposes, ethnographic studies, and licensure and 
certification reports on nursing homes, little is known about the incidence of abuse in institutional 
settings, although all agree that it does exist.13  Also, most existing institutional studies were 
based on relatively small samples and did not provide national estimates of elder abuse prevalence 
or incidence. 
However, one recent study provides, for the first time, national incidence estimates for domestic 
elder abuse and neglect.  This study, The National Elder Abuse Incidence Study,14 found that 
approximately one-half million (domestic) elderly persons were abused and neglected during 
1996.  The information for the national domestic abuse study was provided by State adult 
protective services (APS) offices, which generally coordinate policy and response to domestic 
abuse of elderly and disabled persons, and other sentinel agencies.15 
Methodology 
Sample Selection 
We selected a purposive sample of 11 States (New York, California, Texas, Ohio, Illinois, 
Pennsylvania, Massachusetts, Florida, New Jersey, Tennessee, and Michigan) representing 
approximately 54 percent of the Medicaid recipients receiving services in nursing facilities, 
including skilled facilities, and 61 percent of the total skilled nursing beds.  Additionally, these 
States represented 46.9 percent ($23.9 billion) of Medicaid long term care expenditures for 
nursing facilities in 1996.16  This purposive sample represents States of various sizes and different 
regions of the country.  Michigan initially served as our test State for the methodology.  That test 
resulted in no changes for the instrument used; therefore, we have included Michigans data in our 
findings. 
4
 We identified each sample States agency having responsibility for maintaining nursing home 
abuse complaints.  We asked that office to complete and return a form identifying reported, 
investigated, and substantiated numbers of institutional abuse complaints during calendar years 
1993 through 1997. 
Definitions 
In reviewing existing literature, we identified many categories of abuse and neglect defined and 
used by researchers.  For this inspection, we attempted to choose and define specific types of 
abuse which appeared more readily identifiable for conversion from any States definitions and 
collection systems (manual or computerized process).  However, we started with the Federal 
definitions provided as part of the State and Federal survey and certification processes for long-
term care facilities located at 42 CFR 488.300 (Subpart E), Section 301: 
	 Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or 
punishment with resulting physical harm, pain, or mental anguish. 
	 Neglect refers to failure to provide goods and services necessary to avoid physical harm, mental 
anguish, or mental illness. 
Based on our review, we selected four specific types of abuse as key indicators of recent nursing 
home patient abuse and neglect trends:  physical abuse, inappropriate use of restraints, physical 
neglect, and medical neglect.  The table below provides the definitions for the four specific sub-
categories of abuse and neglect used in this study. 
Physical Abuse	 the infliction of physical pain or injury, including sexual abuse, 
which may result in bodily injury, physical pain, or impairment 
Inappropriate Use  chemical or physical control of a resident beyond physicians 
of Restraints  orders or not in accordance with accepted medical practice 
Physical Neglect	 disregard for necessities of daily living (e.g., failure to provide 
necessary food, clothing, clean linens, or daily care of the residents 
personal necessities) 
Medical Neglect	 lack of care for existing medical problems (e.g., ignoring the need 
for a special diet, not calling a physician when necessary, not being 
aware of the possible negative effects of medications, or not taking 
action on a medical problem) 
Our request letter to the 11 sample States clearly indicated our understanding that their internal 
definitions would differ from those above, as would their means of collecting the requested data 
(see Appendix A).  With this understanding, we asked that States make the necessary conversions 
between their definitions and those we used for this study, reporting to us the process and 
components of that cross-walk. 
5
 During follow-up on data requests, States were provided an opportunity to simplify their 
processes by limiting the number of years to three and the categories to as few as two broad 
categories of abuse and neglect (combining only complaints meeting the definitions above).  This 
proved helpful in a few instances when this was the only way to obtain the State information. 
Further, at any point, after multiple contacts to obtain the requested information, we accepted 
whatever data the States were able to provide. 
Investigations and Substantiations 
Because of limitations of State data reporting systems and differences in their follow-up 
procedures, we were unable to analyze received information about States investigations or 
substantiations of complaints.  Furthermore, we did not analyze how effectively States and 
nursing homes inform patients about their opportunity to report complaints, nor did we determine 
what barriers, if any, may prevent patients from reporting complaints (we will study these issues in 
future reports).  Thus, our study cannot determine the extent to which abuse is actually occurring 
in nursing homes, only the extent to which States report receiving complaints involving nursing 
home patients and the type of complaints they reported receiving.  We are using this information 
in concert with other information to gain a general understanding of conditions in nursing homes. 
State Response 
Eight of the sample States did provide limited data about reported complaints of nursing 
home abuse and neglect in their State, but only two of the sample States were able to 
produce the full data set of abuse and neglect trend information as requested.  The primary 
difficulties for the States proved to be determining what abuse and neglect data their system 
(automatic or manual) captured; which of their data categories could be cross-walked to the 
requested abuse and neglect types; who ultimately had responsibility for responding to such a 
request; and coordinating with other offices to obtain abuse or neglect data not maintained in the 
office designated as the primary coordinator for nursing home abuse complaint.  Once these issues 
were addressed internally, the final difficulty was assigning a staff person to the project and 
ensuring its completion.  Many of the States were unable to have a person perform this function 
full-time for the potentially short period of time necessary (we anticipated two weeks maximum). 
As a result, the project was interwoven with other responsibilities and completed as time 
allowed. 
Of the eleven sample States, only Illinois, Massachusetts, Michigan, and Texas attempted to 
complete the OIG request in the manner specified using the provided definitions to cross-walk 
their available data and reporting the information on the provided form.  Both Michigan and 
Texas complied fully.17 
	 California provided their automated system reports for the years requested with no indication of 
which of their 11 categories of abuse and neglect could be cross-walked to our four specific abuse 
types (however, subsequent conversations with their staff allowed us to attempt this); 
6
 	 Florida provided only the raw data pertaining to nursing home complaints in a spreadsheet, with no 
indication of which complaints were abuse or neglect as defined by that State (subsequently, we 
received printed State reports providing data maintained by Adult Protective Services, 1991 
through 1995, but not reflective of the nursing home environment); 
  Tennessee provided no State definitions for their provided data; 
	 New York provided its applicable State Annual Complaint Reports for 1991-1995 and raw 
counts for the 1996-1997 report, again with no attempt to cross-walk their captured data to the 
requested data; 
	 Pennsylvania was unable to provide any information concerning abuse and neglect trends and 
definitions for the data they collect internally; and 
	 New Jersey was unable to provide the requested information from their manual system, but was 
able to provide the number of overall complaints received each year. 
Individual State definitions for abuse and neglect vary greatly.  Of the 11 sample States, no 
two used the same State definitions for abuse and neglect complaints.  Further, no two used the 
same State definitions or processes for collecting data on  reported, investigated, and resolved 
abuse and neglect complaints.  However, we must note that all of the sample States reported their 
States adherence to the Federal categories of abuse provided in 42 CFR.  One State actually has 
no definitions for specific types of abuse or neglect beyond those provided at 42 CFR.  Most of 
the sample States have some form of broad definition of abuse.  Appendix B illustrates the 
variation in definitions provided in State law and regulations. 
Many of the sample States were unable to cross-walk their definitions of abuse complaints to 
those used for this inspection, primarily because they were unable to devote the necessary 
staff time.  Most of the States expressed concern about the perceived effort involved in 
responding to our data request.  Many were concerned particularly because of the potential for 
taking considerable staff time to convert their States definitions to match those of this study and 
to retrieve the information from the States data collection system (manual or automated).  Also, 
many of the sample States indicated they were in the process of changing, updating, or creating 
automated abuse data collection systems. 
Individual State Results 
Based on available State data, we were able to calculate rough estimates of the extent and 
nature of overall trends for reported abuse and neglect complaints for each State; however, 
we are unable to compare the State results from one State to another.  In order to compare 
States, we would require a common system of defining, reporting, and resolving complaints. 
Lacking this, we are only able to review the reported raw numbers of complaints within each 
State.  The tables below present the abuse and neglect complaints as reported by eight sample 
States - California, Illinois, Massachusetts, New York, Michigan, Ohio, Tennessee, and Texas. 
7
 As can be seen in the following tables, the abuse complaints of nursing home patients are serious. 
We see a consistent reporting of abuse and neglect with each State reporting an increase in 
neglect complaints.  These types of complaints relate directly to quality of patient care in an 
environment which should be ensuring each patients well being. 
California 
Possible Abuse and Neglect Categories  1995  1996  1997  Percent of Change** 
Dietary  135  139  143  +5.9 
Medication  138  150  126  -8.7 
Patient Care  4,804  4,049  3,967  -17.4 
Patient Rights  713  739  730  +2.4 
Neglect/Abuse  743  665  744  +0.13 
TOTAL  6,533  5,742  5,710  -12.6* 
*  The totals for the trend do not reflect the sum of that column. 
**  Trend reported is the percentage of increase or decrease of the raw counts of State-reported complaints between 1995 
and 1997. 
Illinois 
Complaints  1995  1996  1997  Percent of Change** 
Abuse  495  502  567  +14.5 
Misuse of Restraints  18  41  61  +238.0 
Neglect  300  332  408  +36.0 
TOTAL  813  875  1,036  +27.4* 
*  The totals for the trend do not reflect the sum of that column. 
**  Trend reported is the percentage of increase or decrease of the raw counts of State-reported complaints between 1995 
and 1997. 
Massachusetts 
Complaints  1995  1996  1997  Percent of Change** 
Abuse  531  346  273  -48.6 
Neglect  159  190  165  +3.8 
TOTAL  690  536  438  36.5* 
*  The totals for the trend do not reflect the sum of that column. 
**  Trend reported is the percentage of increase or decrease of the raw counts of State-reported complaints between 1995 
and 1997. 
8
 Michigan 
Complaints  1995*  1996  1997  One-Year Change** 
1996-1997 
Physical Abuse  294  739  438  -40.7 
Misuse of Restraints  7  25  20  -20.0 
Physical Neglect  711  1,385  1,672  +20.7 
Medical Neglect  19  82  130  +58.5 
TOTAL  1,031  2,231  2,260  +1.3 
*  The data for this year reflects only a six-month data period (July1-December 31) from the date of the initiation of a new 
data system. Prior data was not accessible. We did not calculate a 1995-1997 trend for this State, but only show a one-
year change between 1996 and 1997. 
**  The totals for the one-year change only reflect the percentage of increase or decrease of the raw counts of State-
reported complaints between 1996 and 1997. 
New York 
Complaints*  1993  1994  1995  Percent of Change** 
TOTAL  1,522  1,481  959  -37.0 
*  New Yorks Chapter 340 Complaints. 
**  Trend reported is the percentage of increase or decrease of the raw counts of State-reported complaints between 1995 
and 1997. 
Ohio 
Complaints  1995  1996  1997  Percent of Change** 
Abuse  1,472  1,865  1,856  +26.0 
Neglect  150  192  260  +73.3 
TOTAL  1,622  2,057  2,116  +30.5* 
*  The totals for the trend do not reflect the sum of that column. 
**  Trend reported is the percentage of increase or decrease of the raw counts of State-reported complaints between 1995 
and 1997. 
Tennessee 
Complaints  1995  1996  1997  Percent of Change** 
Abuse  515  431  429  -16.7 
Neglect  113  110  130  +15.0 
TOTAL  628  541  559  -11.0* 
*  The totals for the trend do not reflect the sum of that column. 
**  Trend reported is the percentage of increase or decrease of the raw counts of State-reported complaints between 1995 
and 1997. 
9
 Texas 
Complaints  1995  1996  1997  Percent of Change** 
Physical Abuse  3,050  3,425  3,718  +21.9 
Misuse of Restraints  337  292  360  +6.8 
Physical Neglect  10,872  9,688  10,331  -5.0 
Medical Neglect  2,322  2,235  2,420  +4.2 
TOTAL  16,581  15,640  16,829  +1.5* 
*  The totals for the trend do not reflect the sum of that column. 
**  Trend reported is the percentage of increase or decrease of the raw counts of State-reported complaints between 1995 
and 1997. 
We were also interested in calculating reported complaints as a percentage of each States nursing 
home population.  To attempt this, we asked each State for the number of nursing home patients 
State-wide for each of three sample calendar years (1995-1997).  However, most of the sample 
States were unable to fully meet this request, and Florida, New Jersey, New York, and 
Pennsylvania were unable to provide any acceptable nursing home patient census.  Only 
Massachusetts and Texas provided sufficient information to calculate the percentage of change. 
The table below shows changes in total complaints over three years as a percentage of the nursing 
home population for these years using the State-provided raw counts.  A more detailed 
description and analysis of each States reported data is found in Appendix C. 
Massachusetts Complaints 
Categories - abuse, neglect 
Percent by Calendar Year  Percent of Change over 3 Years 
1995  1996  1997  1995-1996  1996-1997  Trend 
1.25  0.97  0.79  -22.40  -18.60  (-) 
*  Trend reported is the percentage of increase or decrease of the raw counts of State-reported complaints as a percentage 
of the nursing home population between 1995 and 1997. Total patient numbers are the same for each year, as provided 
by the State. 
Total Complaints  Percent of Change 
1995  1996  1997  -36.5 
690  536  438 
Texas Complaints 
Categories - physical abuse, misuse of restraints, physical neglect, medical neglect 
Percent by Calendar Year  Percent of Change over 3 Years 
1995  1996  1997  1995-1996  1996-1997  Trend 
16.59  15.88  17.53  -4.3  10.4  (+) 
*  Trend reported is the percentage of increase or decrease of the raw counts of State-reported complaints as a percentage 
of the nursing home population between 1995 and 1997. 
Total Complaints  Percent of Change 
1995  1996  1997  +1.5 
16,581  15,640  16,829 
10
 In summary, when we compare the raw counts of reported complaints to the nursing home 
populations in each of the sample States, we find most States report that between 1 and 3 percent 
of their nursing home population had abuse or neglect complaints.  One State indicates a much 
higher percentage of 17 percent.  We believe that this data represents each States reported 
complaints.  However, due to the lack of uniform data systems and definitions across States, we 
cannot draw generalizations from those observations.  We have no way of knowing whether 
States with higher reported abuse complaint levels actually have more abuse occurring, have more 
aggressive abuse reporting systems, or have some other outside influencing factors. 
The State-provided data allow the use of raw counts to show a trend in each State; however, we 
found no consistent trend in reported abuse complaints among all the 11 States.  Some States 
report increases in complaints; others report decreases.  And for the same reasons cited above, we 
are unable to explain the increases and decreases, even within individual States.  The following 
table provides a summary, by State, which shows the result of calculating the trend of complaints 
as a percentage of the nursing home population for a three-year period. 
Trend of State-Reported Abuse and Neglect Complaints 
as a Percentage of State Nursing Home Populations(1) 
Percentage of 
Nursing Home Patient  Complaints to Nursing  Amount of Change Over 3 
Population by Year  Home Population  Years and Trend 
Sample State 
1995  1996  1997  1995  1996  1997  1995- 1996- Trend (5) 
1996  1997 
California (4)  94,239  NA  NA  1.48  NA  NA  NA  NA  NA
Illinois (2)  103,075  102,829  102,583  0.77  0.81  0.95  0.04  0.14  +
Massachusetts (3)  55,000  55,000  55,000  1.25  0.97  0.79  -0.28  -0.18  -
Michigan (2)  34,340  71,586  74,611  2.98  3.08  3.00  0.10  -0.08  NC
Ohio (2)  98,797  102,033  105,375  1.64  2.01  1.92  0.37  -0.09  +
Tennessee (2)  45,464  51,109  57,455  1.38  1.06  0.97  -0.32  -0.09  -
Texas  97,919  96,676  93,951  16.93  16.18  17.91  -0.75  1.73  + 
(1)  Florida, New Jersey, New York, and Pennsylvania were unable to provide any acceptable nursing home patient census. 
(2)  In Ohio, Illinois, Michigan, and Tennessee, the 1997 total patient number was unavailable; we therefore used a linear 
extrapolation of two data points from 1995 and 1996 based on the unproven assumption that change in the number of 
total patients is similar to the previous two years. 
(3)  Massachusetts provided us the same estimated numbers for each year. 
(4)  California was unable to provide the patient figure for 1996 and 1997. 
(5)  Trend reported is the percentage of increase or decrease of the raw counts of State-reported complaints over the 3-year 
period with a leveling effect applied. 
NA Not Available 
NC  No noticeable pertinent change 
+  Increasing 
- Decreasing 
11
 Again, using only the State-provided total raw counts, it appears that the ratio of reported abuse 
and neglect complaints per nursing home patient are fairly stable, with minor increases in Illinois, 
Ohio, and Texas and minor decreases in Massachusetts and Tennessee, with Michigan remaining 
about the same.  However, we are unable to explain the broad differences, ranging from less than 
one percent to 3 percent on average for six of the States to more than 17 percent for one State. 
Actually, differences may not be reflective of more or less abuse complaints occurring in one State 
versus another State.  For example, Texas complaints of abuse and neglect appear to be much 
higher than the other reporting States.  One possible reason for the high reporting of possible 
occurrences may be Texas involvement in Operation Restore Trust in the prior two years. 
During that period, and subsequently, the State and interested patient advocacy and nursing home 
associations within the State provided a great deal of media coverage and education concerning 
abusive situations.  This may be one factor leading to a higher awareness and concern for 
reporting such incidents. 
12
 ENDNOTES
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1.  42 Code of Federal Regulations  483.13. 
2.  Omnibus Reconciliation Act of 1987  1919(g). 
3.  42 U.S.C  3001-3058ee (1994). 
4.	 Long-Term Care Ombudsman Program: Complaint Trends (OEI-02-98-00350), 
Office of Inspector General, Department of Health and Human Services. 
5.	 Assuring the Quality of Nursing Home Care, HHS Fact Sheet, Department of Health 
and Human Services, July 21, 1998. 
6.	 Nursing Home Initiative Update #1, Health Care Financing Administration, 
Department of Health and Human Services, September 15, 1998. 
7.	 OIG sample review of Health Care Financing Administration OSCAR deficiency tags 
for FY 1996. 
8.	 Message from the Administrator, HCFA Health Watch, Health Care Financing 
Administration, Department of Health and Human Services, August 1998. 
9.  Program Instruction, Administration on Aging AOA-PI-98-05, September 29, 1998. 
10.  Older Americans Act,  102(13) and 102(26). 
11.	 Instructions for Completing the State Long Term Care Ombudsman Program 
Reporting Form for the National Ombudsman Reporting System (NORS), 
Administration on Aging, OMB #0985-0005, expiration August 31, 2001. 
12.  Social Security Act  1919(g). 
13.	 Benson, W., Administration on Aging, Testimony to Older American Caucus 
Congressional Hearing, November 5, 1997.  This statement is actually attributed by 
Mr. Benson to Rosalie Wolf, Institute on Aging, Medical Center of Central 
Massachusetts. 
14.	 The National Elder Abuse Incidence Study, National Center on Elder Abuse and the 
American Public Welfare Association in collaboration with Westat, Inc., Final Draft 
Report, Second Revision, July 1, 1998.  This study originated in 1992 when Congress 
directed that a study of the national incidence of abuse, neglect, and exploitation of 
elderly persons be conducted.  This study was jointly funded by AoA and the 
Administration for Children and Families (ACF). 
13
 15.	 Data reported by sentinel agencies are not officially reported to the APS agencies, nor 
are they officially substantiated.  There were four types of sentinel agencies in this 
study: law enforcement, elder care providers (i.e., adult care centers), financial 
institutions (banks), and hospitals, including public health departments. 
16.	 1997 Data Compendium and Medicaid Program and Financial Statistics Fiscal Year 
1996, Health Care Financing Administration, Department of Health and Human 
Services. 
17.	 Michigan and Texas, essentially, use HCFAs survey deficiency tags as their means of 
collecting nursing home abuse and neglect information.  After they determined which 
tags were related to the OIG definitions (for the four abuse categories of physical 
abuse, inappropriate use of restraints, physical neglect, and medical neglect), they 
cross-walked their data to provide us the information requested.  They also provided 
their States definitions of abuse and neglect and any related sub-categories. 
14
 REFERENCES

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Aravanis, S., Adelman, R., Breckman, R., et al.  Diagnostic and Treatment Guidelines on Elder 
Abuse and Neglect, Arch Fam Med, 1993;2:371-388. 
Baumhover, L. and Beall, S., Abuse, Neglect, and Exploitation of Older Persons: Strategies for 
Assessment and Intervention, Health Professions Press, Baltimore, Md., 1996. 
Benson, W., Administration on Aging, Testimony to Older American Caucus, Congressional 
Hearing, November 5, 1997. 
Dolan, R. and Blakely, B., Elder abuse and neglect: A study of adult protective service workers 
in the United States, Journal of Elder Abuse and Neglect, I, 31-49, 1989. 
McDaniel, C., Elder Abuse in the Institutional Setting, University of Kansas, May 1997. 
MacNamara, Creating Abuse-Free Caregiving Environments for Children, the Disabled, and the 
Elderly, Charles C.  Thomas, Springfield, Il., 1991. 
Pillemer, K. and Finkelhor, D., The prevalence of elder abuse: A random sample survey, The 
Gerontologist, 28, 51-57, 1988. 
Pritchard, J., The Abuse of Older People: A Training Manual for Detection and Prevention, 
second edition, Jessica Kingsley Publishers, London, England, 1995. 
Sengstock, M. C. and Liang, J., Identifying and Characterizing Elder Abuse, Detroit, Michigan, 
Wayne State University Institute of Gerontology, 1982. 
Tatara, T., An analysis of State laws addressing elder abuse, neglect, and exploitation, 
Washington, D. C., National Center on Elder Abuse, 1995. 
Tatara, T., Institutional Elder Abuse: A Summary of Data Gathered from State Units on Aging, 
State APS Agencies, and State Long Term Care Ombudsman Programs, Washington, D. C., 
National Aging Resource Center on Elder Abuse, August 1992. 
U. S. House of Representatives, Subcommittee on Health and Long Term Care, Select Committee 
on Aging, Elder Abuse: An Examination of a Hidden Problem, Washington, D. C., U. S. 
Government Printing Office, Publication 97-277, 1981. 
U. S. House of Representatives, Subcommittee on Health and Long Term Care, Board and Care 
Homes in American: A National Tragedy, Washington, D. C., U. S.  Government Printing Office, 
Publication 101-711, Chairmans Report, 1989. 
15
 U. S. Senate, Special Committee on Aging, Nursing Home Care: The Unfinished Agenda, Vols I

and II, Washington, D. C., U. S.  Government Printing Office, Publication 99-19, 1986.

U. S. Senate, Special Committee on Aging, Resident Assessment: The Springboard to Quality of

Care and Quality of Life for Nursing Home Residents, Washington, D. C., U. S.  Government

Printing Office, Publication 101-30, 1990.

Wolf, R. and Pillemer, K., Helping Elderly Victims: The Reality of Elder Abuse, Columbia 
University Press, New York, 1989. 
16
 Appendix A 
Letter to State Agencies Requesting Abuse Trend Information 
Dear Coordinator: 
The Office of Evaluation and Inspections of the Office of Inspector General is responsible for conducting 
inspections designed to determine the effectiveness, efficiency, and vulnerability to fraud, waste, or abuse of 
Department of Health and Human Services programs. We recognize that the primary responsibility for 
designing, operating, and coordinating services for the elderly and disabled lies with the States.  We are 
conducting a study to determine the recent trend in selected categories of nursing home patient abuse 
complaints reported and resolved in selected States. As part of that undertaking, your State has been selected 
as one of the participants. 
While many State agencies have some responsibility for resolving nursing home problems, each State designates 
a coordinator with central State authority to receive complaints of mistreatment or neglect of nursing home 
patients. Based on our research and confirmation within your agency, you have been designated as having that 
role. We would like you to complete the data table provided. Following your completion of the form, we would 
like to know the amount of time the table required for completion. 
Federal definitions of elder abuse, neglect, and exploitation first appeared in the 1987 Amendments to the Older 
Americans Act. However, these definitions were only provided as guidelines for identifying problems, not for 
enforcement purposes.  Currently, elder abuse is defined by State laws, and their definitions vary in terms of 
what constitutes the abuse, neglect, or exploitation of the elderly. Additionally, researchers have used many 
different definitions to study the problem. Yet, in most cases, State statutes provide the necessary definitions 
with varying degrees of specificity. 
The definitions we will use for reviewing four types of abuse in this study are as follows: 
Physical Abuse	 the infliction of physical pain or injury which may result in bodily injury, physical 
pain, or impairment, including sexual abuse 
Inappropriate Use  chemical or physical control of a resident beyond physicians 
of Restraints  orders or not in accordance with accepted medical practice 
Physical Neglect	 disregard for necessities of daily living (e.g., failure to provide necessary food, 
clothing, clean linens, or daily care of the residents person necessities) 
Medical Neglect	 lack of care for existing medical problems (e.g., ignoring the need for a special diet, 
not calling a physician when necessary, not being aware of the possible negative 
effects of medications, or not taking action on a medical problem) 
This means you may need to review and adjust your States definitions of abuse and neglect for nursing home 
patients to conform with the definitions above. This also means you may have to adjust your collected data 
accordingly. 
Please fax the completed form and your written comments to us at 214-767-2039 by {August 7}. We realize 
that this is a short time frame and greatly appreciate your efforts in this endeavor. If you have any questions, 
please contact Leah Bostick of my staff at 214-767-3310 or 1-800-848-8960. Thank you very much for your 
assistance. 
Attachment - Form and Table 
Appendix A - Page 1  Appendix A - Page 2
 Appendix B 
Examples of State Definitions of Abuse and Neglect 
Sample State  State Definition Abuse  State Definition Neglect 
California  No specific definitions; uses 12 categories of abuse, neglect, and exploitation each having no specified 
definition, a subjective decision determine which category to use for reported incident. 
Florida  Non-accidental infliction of physical  Failure or omission on the part of the caregiver of a disabled 
or psychological injury or sexual  adult or an elderly person to provide the care, supervision, and 
abuse upon a disabled adult or an  services necessary to maintain the physical and mental health of 
elderly person.  the individual (including food, clothing, medicine, shelter, 
supervision, and medical services). 
Also means the failure of a caregiver to make a reasonable 
effort to protect a disabled adult or an elderly person from 
abuse, neglect, or exploitation by others. 
Repeated conduct or a single incident of carelessness which 
produces or could be expected to result in serious physical or 
psychological injury or a substantial risk of death. 
Illinois  Physical injury, sexual abuse, or  Failure in a long term care facility to provide adequate medical 
mental injury inflicted on a resident  or personal care or maintenance, which failure results in 
other than by accidental means.  physical or mental injury to a resident or in the deterioration of 
a residents physical or mental condition 
Complaint intake personnel also 
delineate by physical, sexual, verbal, 
and mental abuse as well as by 
sexual assault (only resident to 
resident). 
Massachusetts  Physical contact with a patient or  Failure of a facility or individual to provide treatment or 
resident which harms, or is likely to  services necessary to maintain the health or safety or a patient 
harm, that patient or resident  or resident (certain standards apply). 
(certain standards apply). 
Michigan  State law defines abuse using  Failure, through inattentiveness, carelessness, or omission of an 
HCFAs Guidance to Surveyors- individual to provide timely, consistent, and safe services, 
Long Term Care Facilities, Tag  treatment and care to a facility resident.22 
F223, which is a tool which can be 
used by surveyors in the course of 
conducting a facility survey; 
differentiates abuse, involuntary 
seclusion, mental abuse, 
misappropriation of resident 
property, neglect, physical abuse, 
sexual abuse, and verbal abuse. 
New York  Inappropriate physical contact with a  Failure to provide timely, consistent, safe, adequate, and 
resident of a health care facility,  appropriate services, treatment and/or care to a nursing home 
while such resident is under the  resident which such resident is under the supervision of the 
supervision of the facility, which  facility, including nutrition, medication, and therapies). 
harms or is likely to harm the 
resident (includes striking, and 
sexual molestation) 
Appendix B - Page 1
 Ohio  Knowingly causing physical harm or  Recklessly failing to provide a resident with any treatment, 
recklessly causing a serious physical  care, goods, or service necessary to maintain the health or 
harm to a resident by physical  safety of the resident when the failure results in serious 
contact with the resident or by use of  physical harm to the resident. 
physical or chemical restraint, 
medication, or isolation as 
punishment, for staff convenience, 
excessively, as a substitute for 
treatment, or in amounts that 
preclude habilitation and treatment. 
Texas  Any act, failure to act, or incitement  A deprivation of lifes necessities of food, water, or shelter, or a 
to act done willfully, knowingly, or  failure of an individual to provide services, treatment, or care to 
recklessly through words or physical  a resident which causes or could cause mental or physical 
action which causes or could cause  injury, or harm or death to the resident. 
mental or physical injury or harm or 
death to a resident. This includes 
verbal, sexual, 
mental/psychological, or physical 
abuse (each individually defined). 
Appendix B - Page 2
 Appendix C 
State Specific Information Concerning Abuse and Neglect Complaints 
California reported overall complaints of neglect and abuse generally appear to be 
decreasing.  However, specific complaints of dietary, patient rights, and abuse/neglect problems 
increased slightly.  California was able to provide the OIG with much of what was requested.  The 
State captures complaint information under eleven general (broad) categories, but does not have 
specific definitions for those categories when complaints are reported.  California may also 
categorize a complaint by its potential for serious and immediate threat, requiring prioritizing the 
number of days allowed from when the complaint is received to when it is investigated. 
If we look at Californias neglect/abuse category combined with other, possibly related categories 
(which California was willing to say could be inclusive of neglect or abuse situations), for those 
complaints designated as Priority 1 (investigation within two days) and Priority 2 (investigation 
within 20 days), we see that the overall trend is a drop in reported complaints.  However, if we 
look at each specific Priority 1 and Priority 2 category, reported complaints increased slightly for 
dietary, patient rights, and abuse/neglect.  A significant decrease occurred in patient care 
complaints (17.4 percent). 
When a reported event is received, the responsible staff categorize it as one of these eleven: 
dietary, administration, physical plant, medication, patient care, patient rights, staffing, patient 
record, problem transfer, neglect/abuse, and other.  Surveyors who conduct the reviews or 
investigations can subjectively determine the category in which to place a complaint.  As a result, 
California staff confirmed that their neglect/abuse category does not reflect all the possible 
complaints of abuse and neglect.  A possible neglect or abuse complaint can be categorized in 
another category, i.e., medication could include chemical restraints or medical neglect; patient 
rights could include inappropriate restraints; and patient care could include physical neglect. 
Illinois reported that, overall,  complaints increased, with  significant increases occurring 
between 1995 and 1997.  Abuse increased 14.5 percent with significant increases in neglect and 
restraints, 36 percent and 238 percent, respectively).  This trend of increasing total complaints 
was confirmed when we reviewed the complaints in relation to the number of nursing home 
patients for the same years. 
Illinois routinely collects abuse complaint information in four categories - physical abuse, sexual 
abuse, verbal abuse, and mental abuse.  Definitions for type of abuse and neglect complaints are 
found in two different State laws.  Basically, one set of definitions is for the complaint intake 
process, and the second set is for substantiated complaints when recording of the information is 
required.  All forms of neglect are captured in the one category, neglect.  When a complaint is 
confirmed, it is then defined only by the general terms abuse and neglect for the purpose of 
Appendix C - Page 1  issuing violations.  Restraint complaint information was obtained through a manual search of 
existing records. 
Massachusetts reported a major decrease in abuse complaints, with a minor increase in 
neglect complaints.  Overall, the reported complaints in Massachusetts decreased susbstantially. 
This decreasing trend was also found when we reviewed the number of possible occurrences 
against the number of nursing home patients during the same years.  However, it is interesting to 
note that a concurrent OIG draft report, Long-Term Care Ombudsman Program: Complaint 
Trends (OEI-02-98-00351), indicates that abuse statistics for Massachusetts annual 
Ombudsmans report show significant increases (108 percent for a five year period). 
Massachusetts does not distinguish abuse or neglect within specific categories, choosing to use 
the broad Federal definitions located at 42 Code of Federal Regulations (CFR), section 488, 
Subpart E.  During the intake process of receiving a complaint, the specific type of abuse or 
neglect is identified.  Conversation with staff indicate that the States complaint system provides 
complaint information in a singular category of abuse which includes neglect, with no 
differentiation of specific types.  As a result, in order to provide the neglect category of 
information, a staff person had to manually segregate those complaints. No further information on 
definitions or reporting and collection processes were provided by Massachusetts. 
Michigan reported only six months of data in 1995.  Overall, there was a minor increase of 
1.3 percent in complaints from 1996 to 1997.  However, for estimation purposes, if we double the 
1995 reported complaints (to obtain an annual figure), the result would show a slightly higher 
increase of 9.6 percent in the overall complaints.  When we review the change in complaints 
reported between 1996 and 1997 for specific sub-categories, we see a significant increase in 
medical neglect and a moderate increase in physical neglect, 58.5 percent and 20.7 percent, 
respectively.  Data for that period also indicate a significant decrease in physical abuse (40.7 
percent) and a moderate decrease in misuse of restraints (20 percent). 
Michigan initially served as our test State for the request process.  Given that their system codes 
had no direct relationship to those of the request, they had to conduct the requested cross-walk of 
their data.  This was partially a manual identification and retrieval process conducted in a 
relatively short time period.  Their data reflect allegations rather than complaints, as one 
complaint may have multiple allegations.  Each allegation is designated by type using the States 
defined types of abuse and neglect.  Generally, Michigan uses the typical broad definitions of 
abuse and neglect from both the States Complaint Investigation Manual and the Michigan 
Public Health Code.  However, the manual also provides definitions for the more specific types of 
abuse, including involuntary seclusion, mental abuse, physical abuse, sexual abuse, and verbal 
abuse. 
New Jersey reported their number of overall complaints for calendar years 1995 through 
1997.  The numbers were 1,251; 1,221; and 1,366, respectively.  The State does not use State 
definitions for their abuse complaint system; they do, however, utilize the HCFA survey tags.  The 
Appendix C - Page 2  State Ombudsman office has responsibility for the investigation of physical abuse complaints.  The 
Division of Long Term Care Systems (which provided the complaint statistics) was unable to 
obtain the physical abuse statistics from the Ombudsmans office. 
New York reported a substantial decrease (37 percent) across combined categories of abuse 
and neglect between 1993 and 1995.  New York provided three printed annual reports, Resident 
Abuse and Complaint Investigation Program (reflecting calendar years 1991; 1992-1993; and 
1994-1995).  The 1996-1997 report is not yet available.  New Yorks reports show a small 
decrease from 1993 to 1994 followed by significant decrease from 1994 to 1995. 
It is interesting to note that, as in several other sample States, New Yorks response to the most 
recent Federal surveillance and enforcement regulations enacted July 1, 1995, was a realignment 
of its data collection program to meet the Federal definitions.  The States Patient Abuse 
Reporting Law (Section 2803-d of the Public Health Law), requires the reporting of abuse 
occurrences in all nursing homes.  Allegations resulting from complaints, initially reviewed for 
nature, scope, and severity, are then categorized as either Chapter 340 Complaints1 or General 
Complaints, more commonly referring to facility systemic issues.  New York defines each 
category by the nature of the complaint.  The category of physical abuse includes slapping, 
pushing, holding, kicking, stabbing, exposure, fondling, and raping.  Neglect, or the failure-to-
provide-care category, most commonly includes safe care, appropriate care, adequate care, 
transfer, and restraints. 
Ohio three-year data shows an extremely high increase in neglect complaints (73 percent). 
Abuse complaints also increased by 26 percent.  Ohio provided statistics for the two broad 
categories of abuse and neglect.  It does not collect or report statistics on specific types of abuse, 
such as restraints complaints (Ohio includes restraints in the broad category of Resident Rights 
Issues). 
Tennessee  reported an overall decrease in abuse and neglect complaints; however, neglect 
complaints are increasing.  Tennessees abuse complaints decreased 16.7 percent between 1995 
and 1997; neglect complaints increased by 15 percent. Tennessee, like the other sample States, 
adheres to the Federal definitions at 42 CFR 488.301 for required reporting and investigation of 
abuse.  According to staff, the State does not prescribe any specific definitions for abuse and 
neglect, choosing to use only the Federal definitions.  The State maintains data only for three 
years, plus the current year.  Tennessee is in the process of converting to an automated system for 
collecting and reporting on abuse and neglect. 
1	 New Yorks Laws of 1980, Chapter 340, amended the States Public Health Law encouraged 
reporting of abuse occurrences, strengthened the provisions for immediate action and imposition 
of fines for committing or failure to report abuse, mistreatment, or neglect. The State 
Department of Health continues to refer to complaint allegations of patient abuse, mistreatment, 
and neglect as Chapter 340 complaints. 
Appendix C - Page 3  Texas reported an overall slight increase in the number of complaints received (1.5 percent). 
Yet, when one looks at the four reported categories individually, we find abuse complaints 
significantly increased by 21.9 percent with smaller increases reported for misuse of restraints (6.8 
percent) and medical neglect (4.2 percent).  During that same period, physical neglect reports 
showed a slight decrease of five percent.  When we reviewed the number of complaints in relation 
to the number of nursing home patients in the same years, the slightly increasing trend was 
confirmed. 
Texas abuse and neglect complaint data is collected through a process which utilizes the Federal 
enforcement codes to define the complaints.  This allowed Texas to provide the cross-walk from 
their collected data to the four definitions used for this study. 
Appendix C - Page 4