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RESIDENT ABUSE IN NURSING HOMES 
RESOLVING PHYSICAL ABUSE COMPLAINTS 
Kusserow 
Richard  P. 
INSPECTOR GENERAL 
001 
OEI-0688- APRIL 199 
!I.  , '

EXECUTIVE SUMMARY 
PURPOSE AND BACKGROUND 
The OIG conducted this study to promote a better understanding of abuse in nursing 
homes. This is the second of two report. It examines existing processes for 
resolving physical abuse complaints involving nursing home residents. The first 
report  Resident Abuse in Nursing Homes: Understanding and Preventing Abuse 
examines the nature of abuse and ways to prevent it. 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 
nursing home or elder issues. 
Abuse of the elderly is not a new phenomenon. Research findings and 
Congressional hearings of the 19705 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 membf;rs and caregivers in their homes. Research 
indicates from 1 to 10 percent of the non-institutionalized elderly 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 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. 
METHODOLOGY 
Since natinal abuse statistis are not available and States vary in how they define and 
collect statitis, 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 nursing home abuse 
complaints, or 2) knowledgeable and concerned about nursing home or elder 
issues. 
Respondents, based on their functional expertise and knowledge, answered a wide 
range of questions concerning the current State and Federal 
systems for resolving 
complaints involving nursing home residents. Further
, selected respondents were  asked to provide 1) available statistics concerning complaints received and resolved 
and 2) applicable State laws and/or regulations. The 
experiences and perceptions of 
the participants coupled with a review of State and Federal policies provide the basis 
and recommendations of this report. 
for the findings 
MAJOR FINDINGS 
Systems for reportg abus complaits involvg nursing home residents va among 
States. 
State requirements for reporting abuse and penalties for non-reporting vary. 
Most States have identified an individual to receive complaints of nursing home 
resident abuse, often by means of a "hotline." Yet, reporting does not always 
occur. 
Weaknes exit in 
reslution of and follow-up activties for abus complaints. 
According to many respondents, a lack of communication and coordination 
among involved agencies weakens the complaint resolution process. 
States vary in their interpretations of the investigative responsibilties of State

Ombudsmen and Medicaid Fraud Control Units (MFCUs). 
Prosecution of substantiated abuse incidents is hindered by the difficulty of 
proving the abuse and obtaining the evidence required for prosecution. When 
confirmed, most instances of abuse wil result in staff dismissal but no criminal 
prosecution. 
State and Federa abus recrd-keeping and oversight actties nee strengthenig. 
Analysis of national abuse statistics was not possible because of variations in the 
definitions and  statistics collected under existing State and Federal 
tyes of abuse 
reporting requirements. 
Many respondents familar with the Health Care Financing Administration 
(HCFA) nursing home certification survey guide identified problems with its use 
and application.  RECOMMENDATIONS 
STATE AND lOCAl RESPONSIBIUTES 
Each State should establish a State-wide network of responsibilties and 
supporting processes to report, investigate, resolve, follow-up, and prevent abuse 
in nursing homes. Regardless of the components of the network, a single entity 
must be responsible for its operation. 
States should be permitted flexibilty in deciding how best to establish such a 
system of State agency roles and responsibilties. However, States should 
consider the need to 1) enact new legislation or strengthen existing laws to 
implement this process, and 2) ensure appropriate resources for its operation. 
FEDERAL RESPONSIBIUTES 
The HCF A should require stronger reporting, investigation, resolution, and . 
follow-up of abuse incidents as part of its 
conditions of participation for hospitals 
and nursing homes. 
'1 ( 
The Administration on Aging (AoA) should expand and strengthen its efforts to 
1) issue periodic public reports concerning best practices for preventing and 
dealing with resident abuse, 2) promote public awareness and education 
concerning abuse occurring in nursing homes, and 3) promote use of volunteer 
Ombudsmen in Yall nursing homes. 
The HCF A and the AoA should jointly develop common definitions and 
categories of abuse for all State and Federal reporting purposes. 
ADDmONAl ACTION BY THE OIG 
The OIG will, through its oversight responsibilty, encourage State MFCUs to: 
promptly evaluate reported incidents and complaints of suspected abuse 
and take timely, definitive action, with decisions not to prosecute reported 
to the designated State agency,

foster closer relationships with all local prosecutors involved in abuse cases 
and 
report abuse convictions to the OIG for possible sanctions.  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

EXECUT SUMMAY

INTODUCTION 
Purpose 
Background 
Scope and Methodolog 
FINDINGS 
Systems for reporting abuse complaints involving nursing home residents 
vary among States. 
'1 ' 
Weaknesses exist in resolution of and follow-up activities for abuse complaints. 
State and Federal abuse record-keeping and oversight activities need 
strengthening. 
RECOMMENDATIONS 
DEPARTMENTAL COMMENTS 
APPAEN.DICES
B. National Organization Respondents 
C. State Eldert or Nursing Home Laws and Regulations
D. Degree of Nursing Home Abuse Reporting 
E. Departmental Comments
F. Public Comments
Bibliography  -.. --..-.. ...
ELLY

ACTUAL AND PROJECTE GROWTH OF THE 
PO T1 (65 YE Ol)

NUMBER (IN MILUONS) 
PECEN OF POPULATI 
20 -..-..-..-..-..-.. 
10 -.. 
20 
199 
1970 198  2010 2020
YEAR 
SO Cl PO T1 RES 
CE NIOU. U 
us 
NUMBER (IN MIWONS) 
PERCEN OF POULATI 
FIGURE 1 
PROJECTION OF THE NURSING HOME POPULATION 
65 YEA AND OLER BY AGE GROUP 
C/ 4

3 5  EiSS AND OVER

75 - 84 
D65
20 
Z 0

198  1990  2010  2020 
8I
AI 
YEAR  IO AQ  188-8
PMAN 8Y U oS. 8A!TDI  T1 
ON 
FIGURE 2
 INTRODUCTION

PURPOSE 
The OIG conducted this study to promote a 
better understanding of abuse in nursing 
homes. This is the second of two reports. It examines existing processes for 
resolving physical abuse complaints involving nursing home residents. The first 
report  Resident Abuse in Nursing Homes: Understanding and Preventing Abuse 
examines the nature of abuse and ways to prevent it. 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
71 l 
unprecedented rate, partially as a result of new technologies and medical advances. 
There are now 28 milion people aged 65 or older; by 2030, they will number more 
than 60 millon, 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 will continue to grow rapidly as 
the very old segment of the population continues to expand. 
Projections indicate 3.5 
milion elderly individuals will be living in nursing homes by 2030 (figure 2). The 
growth in the number of older people experiencing both disabilties 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 19705 and 1980s have helped to increase public 
awareness of elder abuse. Exsting 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 treatrpent 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 Servces (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 U.  C. 3001 et seq. authorizes activities for 
)J. 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
facilties 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 will 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 preven  and detect fraud and abuse 
in Department programs. The OIG is raequiredb to 1) urecomsmende policie.s fo r th.e  
detection and prevention of fraud and abuse within 
programs and operations
administered or financed by the Department and 2) conduct
, supervse, or coordinate
investigations related to such fraud and 
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 otherwse 
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 furthet 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, XVII, 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 servce 
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 facilities 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 skilled nursing facilty (SNF) must meet COPs to participate in 
the Medicare or Medicaid programs; intermediate care facilities (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 facilty 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 18610) of the Social Security Act. Current Medicaid standards are in 42 
CFR, Part 442, Subpart D, E, and F. 
Omnibus Budget Reconciliation Act of 1987 (OBRA ' 87).  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 facility 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 or 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 will be required to verify the competency of applicants prior to their 
employment as nurse aides. No nurse aide mflY be employed for more than four 
months unless the individual has completed State-approved training or 
successfully 
passed a competency test. Verifcation 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 will, after notice and reasonable opportunity to 
rebut allegations in a hearing, notify the nurse aide and the nurse aide registry. 
State and Local Roles 
priary 
The  respomibilit for designing, operating, and coordinating services for the 
Severed State agencies may be 
elderly lies with the States. 
 responsible for resolving 
'1 ' 
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 servces, 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: 
to establish procedures for maintaining a State-
wide reporting system 
to collect and analyze data related to complaints and incidents; 
to monitor the development and implementation of Federal, State 
and local laws, regulations, and policies with respect to long term care 
in the State;
 to provide public education on their activities and long term care 
issues; and 
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 facilities 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 
agencies with parallel responsibilties for investigation of fraud and abuse (e.g., State 
Attorney General). 
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). 
statitics are not available and States vary in how they define abuse 
Since natinal abuse 
and collect statistis, we decided to survey knowledgeable individuals involved directly or 
Specifically, the inspection relied on 232 intervews 
inirectly 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 HCF A offices as well as several State agencies (e.g., State 
Ombudsman and single State agency for Medicaid). 
A minimum of three principal entities were intervewed 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 preinspection 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 State& 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. Further, selected respondents were asked to provide 1) available statistics 
, concerning complaints received and resolved, and 2) applicable State laws and/or 
regulations. 
This report focuses on the respondents' perceptions and understanding of existing 
processes for resolving physical abuse complaints. Unlike the other six categories of
abuse, physical abuse is generally easy to recognize and has more 
consistency of 

definition. Further, it is a form of abuse for which States may have developed a

process to resolve complaints. The responses, coupled with a review of State and

Federal policy and available literature, provide the basis for our findings and 
recommendations and 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. 
Phvsical Abuse

Infliction of physical pain or injury.

Examples Include individuals either 1) reactng inappropriately to a situation, such as pushing or slapping a resident, 
or 2) Intentionally doing boily 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 stff 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 
Phvsical Neglect 
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.g., brushing a resident's hair, helping with a resident's bath). 
Medical NeQlect

Lack of care for existing medical problems. 
Examples include ignoring a necessary special diet, not callng a physician when necessary, not being aware of the 
possible negative effecs of medications, or not taking action on medical problems. 
Verbal/Emotional NeQlect 
6. 
Creating situations in which esteem is not fostered. 
Examples include riot 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 
personaLPropert Abuse (  Goods)

7. 
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

* Sta tea Visited Onslte

SURVEY RESPONDENTS BY ROLE

Type of Respondent  Number  ot  All
Respondent 
State 
Complaint  16% 
Coordina tor

35 States Contacted  Survey and Certification

Surveyors 
Alabama  Louisiana  New Mexico MFCUs Or Counterpart  18% 
Alaska  Maryland  New York
Arkansas  Massachusetts  North Dakota  Professional Medical

Licensure Boards

California  Michigan  Ohio
Colorado  Minnesota  Oklahoma Ombudsman  16%

Connecticut  Mississippi  Pennsylvania
Florida  Missouri  South Carolina * Residenl Advocacy

Georgia  Montana  Texas  Organlza tlons

Idaho  Nebraska  Washington
Indiana  Nevada  Wisconsin  Nursing Home  13%
Illnois  New Hampshire  Wyoming * Industry 
Kansas  New Jersey 
National Organizations 
States with no Medicaid Fraud Control Unit 
Consumer. Industry and
Local Law Enforcement 
Federal 
HCFA 
DIG 
FIGURE 4
 FINDINGS 
SYSTEMS FOR REPORTING ABUSE COMPLAINTS INVOLVING

NURSING HOME RESIDENTS VARY AMONG STATES

State reQuirement fo rePOrtng abuse and penales for non-reportng Var. 
While a number of States lack legislation specific to abuse in nursing homes, almost 
all States have laws or regulations protecting the elderly. (See appendix B for a 
partial listing.) Included in at least 43 State laws for the elderly is a requirement 
that abuse be reported. Central to most reporting laws is the requirement for 
licensed medical personnel in a health care facility to report abuse. Some States also 
require reporting by unlicensed staff such as aides, orderlies, housekeepers, dieticians 
and other staff. Some States require anyone with knowledge of abuse to report it. 
Although designated reporters may stil be reluctant to report abuse, fear of penalties 
such as license revocation, fines, or even criminal prosecution may overcome the 
reluctance to report. 
. Stes provide some immunit from liabilit for the reportng of abuse. 
State laws presume the good faith of the person filing a report and grant the 
person some immunity from liabilty. Also, reporting laws may protect the 
reporter ('whistle blower clause ) from being discharged from employment or 
harassment. The 1987 Amendments to the OAA Ombudsman Program 
specifically require States to "prohibit retaliation and reprisals by a long term care 
facility or other entity with respect to any resident or employee for having filed a 
complaint with or providing information to, the Office" of the Ombudsman (OAA 
Sec. 307(a)(12)(J)(ii)). 
va 
. Penaes for noreportng  among States. 
Most respondents (80 percent) indicate there is a State penalty for non-reporting 
of known or suspected incidents of physical abuse. Such penalties are generally 
classified as misdemeanors with a designated fine and/or possible short-term 
prison sentence. Some respondents indicate non-reporting may also result in a 
loss of licensure or monetary fine for the involved facilty. However, 83 percent 
of the respondents who indicated a State penalty for non-reporting, further 
indicate States rarely or never enforce those penalties.  id 
Mo Stes hae 
ab.  an indivdual to recive coPiaint
resid 
ofen by  ne.
ocr.  mea  . Yet. rePOna doe no 
This individual (labeled "complaint coordinator" in this study) may be in any number 
of State agencies, but is usually a staff member of the State nursing home survey and 
certifcation agency. While few States have funded special units to respond to 
nursing home complaints, most States have added the responsibilties of receiving, 
investigating, resolving, and follow-up to existing departments. 
A hotline may be located in the coordinator s agency or in another agency. The 
hotline mayor may not be a toll- hour manned line. When not manned 
free 24-
reports may have to be held until normal working 
hours. Sometimes there are 
several routes for reporting abuse, depending on where th  abuse occurs, who the 
abuser is, or the 
severity of the incident. 
. A signifca percege of respondent (46 percent) believe abus is only
soetme 
or rarely reported. 
Thirty-seven percent of the respondent's said abuse is reported only sometimes; 
nine percent indicate reporting rarely or never occurs. If these respondent 
perceptions are accurate, many cases of abuse go unreported each year. 
Opportnites fo resent, failies or visitors to report abuse are available but 
are no alays us. 
Reasons given by respondents for non-reporting include: 
Residents and/or family members sometimes lac  nowled.&
the 
how and to whom reports of abuse should be made
. Although 
nursing homes are required, as a condition of participation in the 
Medicaid/Medicare program, to explain and display resident rights 
which include how to report complaints, some respondents believe 
this is not done adequately. 
Residents fear retaliation from nursing home staff.  Part of the failure 
of residents to report abuse can be attributed to the nature of the 
nursing home resident/employee relationship. Residents are 
dependent on nursing home staff to respond to their basic needs. 
Some residents fearing retaliation (real or imagined) may choose to 
endure the suffering rather than risk the consequences of reporting 
acts of abuse. Similarly, residents, as well as family members, fear 
the nursing home might retaliate by 
discharging the resident for 
report of mistreatment.  Physical or mental ilness limits reporting. Many respondents report 
most vulnerable to abuse are physically or mentally 
that the residents 
impaired and Even those 
, consequently, have diffculty reporting. 
aware something is wrong may be unable to articulate their concerns 
abuse because of those 
or to recognize the perpetrator of the alleged 
impairments. The reporting and subsequent activities to resolve the 
complaint may be physically and emotionally taxng. Consequently, 
residents may simply choose not to report and thus avoid any further 
stress. 
. Ab  st. 
go 
ofen  unrepoed by nursing home 
When asked specifically how often abuse is reported by nursing home staff, many 
respondents (51 percent) believe abuse is only sometimes or rarely reported by 
nursing home staff. This indicates many cases of abuse may go unreported by 
staff. Respondents believe the primary reasons staff do not report abuse include: 
a basic fear of losing one s job

the sense of loyalty shared among staff

fear of retaliation by the nursing home or peers 
fear of fines or penalties

fear of bad publicity, 
, and 
lack of clear or suffcient facts
failure to recognize the less blatant forms of abuse. 
According to one patient advocacy group, "almost every nursing home 
administrator (they) speak with seems to have a different view of what has to 
reported and when." This advocacy group has "seen very inconsistent application 
of reporting requirement timeframes. The requirement that the reporting be 
immediate' is usually ignored. 
resnt 
. A maor of  say atending nursing home physician rarely or 
ab; 
neer report  a lage number indicae emergency room physicians also 
rarely or never rep abus of nursing home resident. 
Approximately 66 percent of the respondents report physicians attending nursing 
home residents rarely or never report abuse (appendix C). In fact, one State 
complaint coordinator reported never receiving a complaint from an attending 
physician. A large number of respondents (37 percent) also believe emergency 
room physicians rarely or never report abuse of nursing home residents who are 
injured severely enough to require emergency care.  Nearly half of all respondents (47 percent) say lack of frequent involvement with 
the residents is a primary reason nursing home physicians rarely report abuse. 
, Some respondents believe emergency room physicians may not report because 
they are more concerned with the immediate treatment of the resident and either 
. abuse. According to respondents 
are too busy to report or do not recognize the
other common reasons physicians, in general, may not report abuse are: 
identification with the staff and their problems in coping with 
residents 
busy schedules

apathy, 
insuffcient facts

belief the incident has already been reported, and 
may be unaware of requirement to repor.t. 
WEAKNESSES EXIST IN RESOLUTION OF AND

FOLLOW-UP ACTIVITIES FOR ABUSE COMPLAINTS

Accrding to man respondent. State and Federal procures for reslvnQ 
abuse complaint are inadequate. 
Respondents perceive many overlapping and sometimes conflcting responsibilties of 
the involved local, State, and Federal entities. As a result, even in States with 
established procedures, there are weaknesses in the current systems to protect 
nursing home residents and to prevent abuse. 
Of those respondents who reacted to  effectiveness of current 
questions about the 
State and Federal efforts to protect residents from abuse, 41 percent indicate State 
systems are no better than "somewhat effective" at protecting residents. Of those 
respondents familar with Federal responsibilties, 55 percent indicate the Federal 
roles are only somewhat effective in resolving abuse of nursing home residents. 
Repont rep 
inaduacies in communicaon an cordinatn 
th ma Ste an  reslut 
Federal agencies having roles in the  of abus 
coplaint. 
Many States have several agencies 
Assessing and resolving abuse is rarely simple. 
with parallel or overlapping roles which receive, investigate or resolve abuse 
complaints involving nursing home residents. A report by the American Public 
Welfare Association and the National Association of State Units on Aging (1986) 
identify 30 possible tyes of State agencies having roles in either the nursing 
home or the community.  Through contacts with the State agencies, we tyically found at least four State 
entities usually involved with investigation and/or resolution of complaints 
involving abuse of nursing home residents: 1) the complaint coordinator, 2) the 
Ombudsman, 3) the MFCU or State counterpart, and 4) local law enforcement. 
In addition to these State entities, some respondents were familar with 
responsibilties of two previously identified Federal agencies: the OHDS/AoA 
and HCFA. Few respondents, other than the MFCUs, had any knowledge of the 
role and responsibilties of the OIG. Most respondents were unfamilar with any 
investigative role by Federal agencies. A few indicated HCFA might perform an 
respondents indicate HCFA and the AoA do not 
investigative role. Additionally, 
concerning individual abuse complaints and 
usually participate in investigations 
rarely have direct involvement in processes for resolving complaints. 
Respondents indicate States have some process in place for resolving abuse 
complaints. However, no one State or Federal agency has responsibilty for the 
full resolution process and for assuring all applicable entities are involved. Thus 
the process can be impeded, particularly when clear role definitions are lacking. 
In many instances, the involved agencies operate through informal agreements 
with the State agency empowered to levy sanctions. Unfortunately, these 
agencies may not report back with their findings and resulting actions in a timely 
manner. 
Many respondents identified weaknesses in State or Federal processes for 
coordination and communication among appropriate agencies. Communication 
coordination, division of responsibilty, and rel tive activity differ among States 
and among State and Federal entities. Even those few States with special units 
to investigate, resolve, and ensure follow-up activities of abuse complaints 
involving nursing home residents exhibit weaknesses in performing some of the 
essential functions (e.g., lack of communication with the OIG). 
To summarize respondent concerns about inadequate coordination of investigative 
agencies, we present the following quote from a elder advocacy group concerning 
a particular state: 
We are concerned that there appers to be less than desirable

arrangements to cordinate investigations of alleged abuse with other

investigative agencies. Most notably, there is an apparent lack of

cordination between the Patient Rights Investigation and Monitoring

Setion and the  In almost

ca  Attorney General's Health Care Fraud Unit. 
all  involving alleged abuse of nursing home residents, we fie

complaints with both offce. We have seen little evidence that

investigations are cordinated in any significant way.
 " "
init 
Winhilee mso, S tes hae reignuela sor  laws governing the  ha oef asnlis 
ma respont indice their Ste doe no 
timpe liemit  fo iconpelngs    or st wi invesgaae bb.a ground 
ty 
to  all  regardles of the  of alleged 
The time frames for an investigation by the authorized entity vary among States. 
Some States are vague and call for- action "immediately,  promptly" or "as soon 
as possible." Those with definite time limits may range from ''wthin 24 hours " to 
'wthin three days." Some State investigation agencies have been given the 
authority to determine the urgency for complaint investigations. Consequently, 
they have the authority to delay investigations. 
How an investigation proceeds is nearly as important as when an investigation 
occurs. Complaints should be in,:estigated with the goal of quickly substantiating 
or negating the complaint. This process should determine the validity of the 
complaint while protecting the rights of both the abused individual and the 
suspect. 
When the investigation does take place, investigators should be familiar with 
investigative techniques, prosecutorial requirements of evidence, and intervewing 
techniques specific to the disabled or elderly nursing home resident. Yet, many 
respondents indicate these are deficiencies of many investigations. Some 
respondents believe the investigative function is also weakened by a lack of 
suffcient investigatprs and a need for medical expertise to support some 
investiga tions.

. Respoden indicae th primar invesgator for mos nursing hoe abus 
wh 
th 
complaint is  nursing home administator or someone to  s/he has 
delegated this responsibilit. 
Complaint coordinators may investigate the situation themselves or delegate the 
responsibilty to others such as a local social worker or the local police. When 
the incident is not severe in nature, as many are not, the complaint coordinator 
may delegate the responsibility for the investigation to the nursing home 
, or someone to whom s/he in turn has 
administrator. The administrator
delegated the responsibilty, will investigate and report the findings to the 
complaint coordinator. In some cases, administrators may initiate investigations 
and take corrective action but fail to report the incident. 
lo 
Ma respoden repo  law enforcement autories are rarely involved 
th invesgat 
in  or resluton of nursing home abuse. 
Respondents indicate police are rarely called for incidents occurrng in nursing 
homes. The severity of the abuse usually dictates whether or not there will be 
15  police involvement. If an incident of abuse is reported to the police, they may 
choose not to work closely with other involved agencies. If they receive an abuse 
complaint involving a nursing home resident, many respondents indicate the 
police will refer the reporter to another entity because they feel no responsibilty 
to deal with "nursing home issues" involving no perceived criminal activity. 
If police are mandated to report and investigate abuse incidents reported to 
them, they must know whom to contact concerning a harmful situation requiring 
non-police remedies. Additionally, respondents believe a lack of knowledge by 
the police in dealing with elderly or disabled nursing home residents wil impact 
on how effectively they perform their investigations. While police clearly have a 
role in investjgating physical abuse and theft of propert, their responsibilty is 
less clear when the complaint is one of misusing restraints or verbaVemotional 
abuse or neglect. 
In those instances in which the complaint is referred to and investigated by the 
police, many respondents indicate the police rarely report their findings to other 
State agencies. Most State Ombudsmen and complaint coordinators have no 
means of tracking the progress of the case (e.g., substantiation, arrest 
prosecution) except, possibly, to obtain a copy 
of the police investigative report. 
These respondents voiced the same concern for referrals made to the MFCU. 
Further, in those States requiring nursing home administrators to report incidents 
to the police, as well as to the coordinator, there may be no measures to ensure 
such compliance.

Stes var in their interpetons of the invesgate resPOnsibilites of State 
Ombudsmen and MFCUs. 
Both State Ombudsmen and MFCUs have Federal mandates to investigate abuse 
complaints involving residents in nursing homes. However, States interpret those 
responsibilties and perform those functions differently. 
Several MFCU respondents indicate different interpretations of which abuse 
complaints they are to investigate. Some investigate only those complaints involving 
residents receiving Medicaid, while others investigate abuse complaints involving any 
resident of a Medicaid-certifed facilty. A few MFCUs may investigate abuse 
complaints regardless of Federal certifcation. 
State Ombudsmen have a similar problem. Operation of ombudsmen programs are 
not uniform within or among States. No Federal regulations interpreting the 
investigative responsibilties of the Ombudsmen have been established by the AoA 
Respondents report State Ombudsmen often lack authority over 
the actions of local 
ombudsmen even though they certify the local ombudsmen. In many instances
, it is  the ombudsman at the local level who will receive and "investigate" an abuse 
complaint. Yet, the State Ombudsmen generally lack adequate direction, resources 
and authority to ensure and enforce a consistent interpretation of the investigative 
role. 
Additionally, both Ombudsmen and MFCU respondents report they are inadequately 
staffed to perform all investigations o  abuse effectively. Respondents say funding 
for more staff would be needed to accomplish such goals. 
aIn muot  Stes, Ste Ombauecn.  serve as a refrral source bu do not hae
to tae displina 
Most Ombudsmen may receive reports of abuse but must refer them to other 
agencies for action. They generally do not investigate the cases themselves. If 
an investigation is conducted by the Ombudsmen, it' is usually parallel to an 
investigation being done by a designated investigatory agency (e.g., survey and 
certification). Although the Ombudsmen may substantiate complaints, they 
generally lack any sanctioning authority. They often rely on the nursing home . 
certifcation and licensing agency or other 
appropriate designated agency for 
administrative remedies, and locl taw enforcement or the MFCU for 
prosecution. 
respo 
unfilia wi 
. Mos  are  the responsibilit of the MFCU to 
invesgate and rese coplant of nursing home resident abus. 
Typically, respondents are not aware of the MFCU or its responsibilities for the 
investigation or resolution of abuse complaints. As a result, many MFCUs may 
not be routinely notifed of abuse 
complaints received by other agencies. 
The MFCUs can receive complaints directly from the reporter. At its discretion 
and if an initial review of the complaint indicates substantial potential for criminal 
prosecution, the MFCU may investigate the complaint or refer it to an 
appropriate criminal investigative (police) or prosecutive authority (local district 
attorney). If the initial review does not indicate substantial potential for criminal 
prosecution, the unit will usually refer the 
complaint to an appropriate State 
agency (survey and certification or professional licensure) for appropriate 
administrative action. 
Many MFCUs are not informed of complaints and incidents until after the 
complaint coordinator investigates and substantiates the complaint. Respondents 
from some States say substantiated complaints will usually be referred to local 
prosecutors rather than to the MFCU. According to respondents, by the time 
many MFCUs are notified of a substantiated complaint investigated by another 
agency, some of the evidence needed for successful prosecution may have been  lost. Such loss of evidence may occur through an insufficient initial investigation 
conducted by an individual not adequately trained in criminal investigative 
procedures and the evidentiary requirements 
necessary for successful prosecution. 
MFCU and counterpart respondents cite the following weaknesses in the abuse 
investigative functions of their States:

lack of coordinated investigative and resolution efforts between local 
law enforcement and other State and Federal agencies 
lack of public awareness to 
recognize and report abuse 
inadequately trained personnel conducting investigations 
insufficient numbers of staff to conduct investigations 
low priority given to abuse complaints not serious in nature 
overly stringent evidentiary requirements for prosecution 
, and 
substantiated complaints under criminal laws
insuffcient enforcement of existing laws and regulations. 
In recognition of these and other weaknesses, the National Association of 
Attorneys General, through the efforts of the National Association of MFCUs 
passed a resolution in 1988 encouraging the States to adopt model legislation to 
prohibit patient and resident abuse. 
Proson  subsated 
of  abuse incident is 
hindered by the difcult of 
inans    proson. 
provinQ the abuse  obtninQ the evidence reauired for  When 
cormed. mo  of abus will result in staf dismiss but no crminal 
proson. 
Across the nation, State penalties for confirmed abuse vary widely. Many laws 
governing prosecution of abuse were established for criminal assault cases. The 
evidentiary requirements for criminal assault are usually much more stringent than 
can be readily satisfied in instances of nursing home abuse. Many complaint 
coordinators urged giving abuse issues a higher priority for investigation and 
prosecution by police and local district attorneys. 
In many instances, respondents said prosecution of substantiated abuse does not 
occur because:

the incidents may be perceived as minor and more easily handled 
administra tively; 
assembling the case can be difficult;

prosecution may not be '
a sure thing

the time lapse to prosecution may lessen the chances of successful

prosecution due to the mental or physical frailty of the victims or witnesses;
 '. 
the abused individuals and witnesses may be reluctant to testify, particularly 
if the victim is the only witness or the witness may be confused as to the 
details of what actually happened; and 
patterns of abuse may not be apparent, because repeated incidents may not 
have been identifed and tracked. 
Respondents say prosecution of a sub
stantiated abuse complaint is rare. As a result 
most confirmed instances result in dismissal of the involved employee. However, the
employee may be retained by the nursing home following an incident of 
less severe 
abuse. In these instances, the employee may be placed on probation and may 
undergo further training and/or counseling. 
STATE AND FEDERAL ABUSE RECORD-KEEPING

AND OVERSIGHT ACTIVITIES NEED STRENGTHENING

There are no adeauate natonal nursina home abuse 
statstcs to provide an
incidence rate or trend for nursina home abuse. 
Nearly all respondents believe abuse, both mistreatment and neglect, is a problem in
nursing homes. Unlike other categories of abuse, physical abuse is generally easy to 
recognize and has more consistency of definition. For this reason, we asked State 
complaint coordinators and Ombudsmen for statistics related to physical abuse. 
While a few States w re able to give us either the number of complaints received or 
incidents reported by nursing homes for combined categories of abuse, most did not 
provide numbers for physical abuse. 
State complaint coordinators in 26 of the 35 States were unable to report 
physical
abuse statistics. According to these respondents
, present record-keeping procedures
do not provide for easy extraction (barring a maIUIaI count of every complaint
received). Exlanations for a State s inabilty to provide information range from not 
having any system for recording complaints to not defining nursing home physical 
abuse as a specific complaint category in their record-
keeping system. 
National summary data is lacking due to: 
limited capacity of State information 
systems to provide detailed data on 
abuse categories 
variations in the definitions and 
tyes of abuse covered by existing State 
and Federal reporting requirements, and 
weaknesses of State and Federal reporting and 
statistical analysis 
requirements regarding abuse problems occurring in institutional 
settings.  st 
de ab 
Ma Stes  an cole  infrm difen. 
States vary in their reporting definitions and practices. Even if a State has an 
information system capable of providing abuse information, definitional 
differences exist which make it inappropriate 
to compare States. For example: 
States vary in how they define individuals protected from institutional 
abuse. Some State laws require reporting of abuse for anyone in a 
nursing home, while others require reporting of abuse specific to the 
elderly. 
Some States define abuse categories 
extensively, while others may 
only have a single category for all tyes of abuse. 
Some States lump incident reports from residential care facilities and 
long term institutions together (e.g., mental health/retardation 
institutions, boarding homes). 
Some States keep statistics on the number of complaints, while others 
keep statistics by allegation. 
Within each complaint, there may be 
one or more allegations. The complaint would be substantiated if just
one of the allegations were true. 
. Th Ste Ombudma
s annual report to AoA has definitona problems which 
us fo ansis 
limit it  of natnal incidence trends or the prevalenc of 
detl 
abus. The level of reportng  is too broad for adequately monitoring
hoe resnt 
nursing  abuse problems and trends. 
State Ombudsmen are required by the OAA to collect and submit complaint data
annually to the AoA. In fiscal year (FY) 1987, seven States either failed to 
report or did not use the AoA Complaint Classification System. The remaining 
43 reported 62 941 complaints in nine major categories and an aggregate "other 
category. The majority of the complaints were for incidents in nursing homes. 
The nine major categories contain 136 subcategories covering 1) resident physical 
medical, and emotional care, 2) administrative problems, and 3) environmental 
issues. Of these, approximately 65 represent complaints which would most often 
fall under the broad category of abuse as defined by this study. However, the 
current and revised reporting forms being implemented require only 
aggregate 
information for most complaint tyes. This weakness wil not allow for the 
reporting and analysis of complaint sub-categories (e.g., Resident Care is the 
aggegate category; improper restraints, physical abuse, mental abuse, verbal 
abuse, neglect, etc., are sub-categories not reported to the AoA for national 
analysis).  Respondents also noted problems in how abuse 
allegations and complaints are 
recorded. A complaint may be reported in several different categories. It may
reflect a single incident or several incidents. Respondents indicate the 
complaint
with several incidents may be recorded as a single complaint, recording only the
primary incident, or as several complaints each based on one incident. 
Therefore, while the Ombudsman report is a major indicator of the 
occurrence of 
nursing home abuse, it cannot be used to obtain reliable national counts of abuse 
(particularly for specific problem areas). 
Man respodent failiar wi 
the HCFA nurs!nhome cert  on survey au 
wi it  an 
idented problems  use  applicaon. 
State survey agencies monitor the performance of nursing facilties by 
determining
their compliance with the Federal conditions of participation. The HCFA has 
oversight responsibilty for the surveys conducted by States for Medicare/Medicaid 
certifcation of nursing facilties. Of those respondents familiar with the 
Medicare/Medicaid Skilled Nursing Facility and Intermediate Care Facilty 
Survey
Report, which is used by State surveyo  , respondents cited several inadequacies of
the HCFA and State 
survey processes and guides, as listed below. 
Survey deficiencies are facilty oriented. Abuse is more often an individual 
issue rather than a facilty-wide problem. 
Because resitdo'ent intervews are of short duration
, surveyors may lack time 
to gain the resident s confidence and overcome his/her fear of reporting the 
abuse. 
The survey processes leave little time for extensive investigation of 
problems. 
Surveyors are not trained investigators. 
Survey conduct varies considerably among States and Federal regions with 
respect to the intensity, focus, and quality of effort and 
resources invested. 
Survey guidelines are subject to varyng interpretations by the individual 
surveyors. What one cites as a deficiency, another may not report due 
extenuating circumstances.
 Re 
repo survor ofen perfrm lite or no analis of coplaint 
pr  coucng  Ste 
to  Fedal or  nursing home surveys. 
Nearly half of the respondents (47 percent) said analysis of prior nursing home 
complaints either does not occur or they were unaware of it being done prior to 
surveys. The usual reason given for this is the surveyors lack easy access to 
complaint fies or all statistics specific to the nursing home being surveyed. 
RECOMMENDATIONS 
Respondents have identifed many overlapping and, in some instances, conflcting 
, State, and Federal entities. As a result, even in 
responsibilties of the involved local
States with established procedures, there are inconsistencies and weaknesses in the 
current systems with regard to protecting nursing home residents and preventing 
abuse. Based on these findings, we recommend the following: 
STATE AND lOCAL RESPONSIBIUTES 
Each State should identify the various State authorities and interest groups with 
current responsibilty for reporting, resolving, and follow-up of abuse complaints. 
Each State should establish a State-wide network of responsibilties and 
supporting processes to address abuse in nursing homes. The network must have 
a single entity accountable for its operation, although functions can be delegated. 
At a minimum, the network should include the following components: reporting, 
investigating, resolving, and follow-up action on abuse complaints. 
Reportina and Investiaatina 
Procedures should be established to receive and act on complaints of suspected 
abuse in a timely manner. Processes for reporting should be easily accessible and 
well publicized. There should be a central agency designated to coordinate the 
receipt of all abuse complaints. This entity should: 
require facilty staff to report all instances of suspected abuse directly to the 
agency designated for that purpose. Mandatory reporters should include all 
licensed or unlicensed professional and non-professional nursing home staff 
including nurses, doctors, administrators, nurses aides, orderlies 
housekeeping, kitchen staff, etc.  There should be a mandatory orientation and ongoing training for all 
employees affected by the reporting requirement. 
The nursing home administrators should not be allowed to delay 
reporting of possible cases of abuse.in order to conduct internal 
investigations. 
prohibit retaliatory action against individuals reporting suspected incidents 
of abuse and provide anonymity when possible. 
take all necessary actions to ensure each abuse report is investigated timely, 
including: 
notifyng the local police and the MFCU (if there is one) of any 
incident or complaint of suspected abuse, and 
notifyng other appropriate State or local agencies responsible for 
supervsing nursing facilties or personnel of the complaint. 
Resolution and Follow-up 
The process should: 
ensure all necessary actions to a) provide appropriate medical care
, if 
necessary and b) resolve the complaint timely, 
maintain communication and coordination among all involved entities 
required for case resolution, and 
document the resolution of each complaint and incident. 
Each State should: 
maintain readily retrievable data about abuse incidents and 
complaints, review and identify patterns of abuse, and then take 
appropriate action when patterns are identified; 
ensure appropriate follow-up activities are performed (e.g., reporting 
substantiated incidents involving aides or medical personnel 
to either 
the aide registry or the State licensure authorities); 
promote public and facility awareness of abuse and reporting 
requirem  nts; 
maintain retrievable statistical data for State management and Federal 
review; and 
report all abuse convictions to State licensure authorities and to the 
HHS/OIG for possible Federal sanctions against the individual or 
facilty.  Administration 
Regardless of which entities are utilzed in performing necessary roles in the 
system, ultimate responsibilty for communication and coordination among all 
State and Federal roles must rest with a single clearly-identifiable entity. That 
entity should:

define individual roles and specify responsibilties of entities involved in the 
receipt, resolution, and necessary follow-up of abuse; 
establish wrtten protocols for conducting abuse investigations; 
ensure qualified staff perform each function of the complaint resolution 
process; and 
require reporting of all local level convictions to the designated central unit. 
States should be permitted flexibilty in deciding how best to establish such a 
system of agency roles, responsibilties and implementing procedures. Possible 
agencies which might have roles in the system include: 
MFCUs 
adult protective servces agencies

local police 
local area aging agencies 
State survey and certification agencies 
State Ombudsmen, and/or 
new State and local agencies created for this purpose. 
States should also consider the need to enact new legislation 
or strengthen 
existing laws to implement this process, and ensure appropriate resources for its 
operation. Wherever possible, formal agreements among 
involved State agencies 
and between State and Federal agencies should be developed which specify their 
respective responsibilties. 
States should further plan, develop, and implement public education programs to 
inform the public about what constitutes abuse and what actions should be taken 
if abuse is suspected.  FEDERA RESPONSIBIUTES 
The HCFA,as part of its conditions of participation for hospitals and nursing 
homes, should: 
require all nursing home staff and hospital medical personnel to report all 
suspected incidents of nursing ,home resident abuse to the nursing home 
administrator or local law enforcement, and to the central agency assigned 
responsibilty for resolution of abuse complaints; 
require nursing homes to report all abuse incidents to local law 
enforcement, the central agency assigned responsibilty for resolution of 
abuse complaints, and to the State survey and certification agency; 
require nursing homes to maintain reports of suspected incidents of abuse 
and the actions taken by the nursing home; 
require administrators to conduct analysis of all incident reports to 
determine implications and appropriate actions; 
require nursing homes to specify, as part of the nursing home resident 
plan of care, a plan to prevent abuse of a resident who is either mentally 
or physically unable to protect him/herself; and 
require nursing homes to provide ongoing training, monitoring, and 
counseling of employees suspected of abusing residents. 
The AoA should expand and strengthen its efforts to: 
issue periodic public reports concerning best practices for preventing and 
dealing with resident abuse;

promote public awareness and education concerning abuse occurring in 
nursing homes; and 
promote and ensure more widespread use of volunteer Ombudsmen in all 
nursing homes. 
The HCF A and the AoA should jointly develop common definitions and

categories of abuse for all State and Federal reporting purposes.
 ADDmONA ACTION BY THE OIG 
The OIG will, through its oversight responsibilty, encourage the MFCUs to: 
promptly evaluate reported incidents and complaints of suspected abuse 
and take timely, definitive action, with decisions not to prosecute reported 
to the designated State agency.

foster closer relationships with all local prosecutors involved in abuse cases 
to: 
a) provide technical assistance and expertise in prosecuting abuse, and 
b) ensure MFCU awareness of abuse convictions by local prosecutors. 
report abuse convictions to the OIG for possible sanctions.  , "
DEPARTMENTAL COMMENTS

Comments were received from th'e Assistant Secret  ry for Planning and Evaluation 
the Offce of Human Development Servces, the Administration on Aging, and the 
Health Care Financing Administration. (See appendix D for the full texts. 
Sere 
Assistat  for Planning and Evauation (ASPE) 
The ASPE agreed with the finding!; 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, improved abuse complaint invt?stigation and resolution as 
part of State enforcement of Federal nursing home regulations, and improved 
systems for abuse reporting. 
Ofce of Human Deelopment Servces (OHDS) 
The OHDS concurred with the report. 
Aging (AoA
Administrtion  on 
The AoA agreed generally with the findings and recommendations of the report. 
However, while concurring with the "observation that there are no data which can be 
used to provide an incidence rate or trend regarding nursing home abuse," the AoA 
states it is beyond their control to overcome the impediments to the collection of 
such data. Thus, they requested the recommendation for the AoA to issue periodic 
public reports on abuse trends be revised to read 
to issue best practices for 
preventing and dealing with resident abuse. 
We recognize the concern expressed by the AoA and have modifd this 
recommendatin. However, we contiue to believe such report will be possible if 
consistent defmitns are developed. 
Financing Administrtion (HCFA)

Hea  Ca 
While HCF A generally agreed with the report, it did have concerns with the primary 
data gathering technique utilzed, that is, an opinion survey rather than a scientifically 
controlled review, which resulted in such opinion data "presented as fact." The 
HCFA also felt it would be advisable to include more information about the 
intervews and information gathering processes used in the study.  . .
Additnal 
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 inicated, there was litle relevant 
statistial or applicable published research data concerning abuse in a nursing home. 
We started with an assumption that inividuals who routinely receive complaints of 
abuse, survey for indicators of abuse, investigate abuse, or resolve abuse incidents are 
knowledgeable sources.  The  survey method was designed to provide descriptive
infonnatin of exting 
processes using statements of opinion from 
a representative
population. Finings and recommendations 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 statistics and legilatin/regulatin, and
available research. We recognize the infonnation provided by the respondents is
signifzcant only in the way it is regarded by the researcher or the 
readers. There is no 
absolute interpretatin of the infonnatin provided. 
Generally, HCFA agreed with the 
recommendations of the report. The HCFA 
believes their implementation of the applicable statutory requirements of the 
Omnibus Reconciliation Act (OBRA) of 
1989 and the Social Security Act 
will fulfil 
most of the recommendations of the report. In meeting a portion of the legislative
requirements, HCF A has revised the conditions of participation for 
nursing homes
(effective October 1, 1990). The HCF A believes the revised requirements will
contain many of the safeguards recomm6nded by the OIG. 
The  HCFA indicates many of the recommendations will be met by the new regulatins.
We agree that draft regulations 
issued thus far represent a substantial improvement over
regulations now in effect. However, some of these regulations are still in the public
review and comment stage and may change. Even more importantly, the regulatins 
defer to State law on the critical issues of complaint reporting, investigating, and follow-
up. Hence, their impact will depend greatly on how aggessively the States move on 
these problems. Similarly, nursing homes will have to comply with the State 
law. We 
wil, therefore, defer any assessment of whether our recommendatins have been 
implemented unti the new regulatory requirements are in place and States and nursing
homes have made at least initil efforts to implement them. 
The HCFA also took exception to aspects of some of the recommendations: 
The HCF A did not agree with the recommendation for hospital medical personnel to 
report suspected incidents of abuse. The agency is unaware of a significant abuse 
problem in hospitals and do not believe there is a need to revise the conditions of 
participation for hospitals since they require hospitals to 
follow State law. Further 
HCFA does not believe the OIG has demonstrated a 
significant problem with respect 
to hospitals.
 We agree that the inpectin did not inicate abuse occurrg in the hospital settg; this 
was not the intent of the stuy. However, the inspection findings did inicate that 
emergency room physicians may rarely or never report abuse observed or treated involving 
a nursing home resident. For clarifiatin of the recommendation, we have modifed the 
recommendatin to require hospital medical personnel to report suspected abuse 
involving a nuring home resident. 
The HCF A disagrees with the recommended requirement for nursing homes 
report "all abuse incidents to local law enforcement, the central agency assigned 
responsibilty for resolution of abuse complaints, and to the State Survey and 
Certifcation Agency." The agency believes the new requirements to report to the 
nursing home administrator or outside official in accordance with State law will be 
sufficient. Further, HCF A believes minor abuse incidents can be effectively handled 
by the administrator without the need for involvement of law enforcement personnel. 
We agree that reportg alleged abuse to the administrator and to an outside entity in 
conjunctin with State law (which we believe should be a designated central agency) 
may be suffcient in most cases. However, we 
disagree that there is no need for 
involvement of law enforcement personnel. We understand HCFA's reasons for minor 
cases not to be reported to the police: Ynfortunately, the distinction between minor 
abuse and major abuse is subjective and cannot always be left to the nursing home 
administrator to determine. We have noted that criminal investigatins should be 
conducted by trained investigators who can make such distinctions. Nevertheless, we 
have modified the recommendation to require reportng to either the nursing home 
administrator or to law enforcement offials as well as to the central agency responsible 
for abuse.

The HCFA, finally, disagrees with the recommendation for nursing homes to provide 
ongoing monitoring and counseling of employees suspected of abusing residents 
stating counseling could be inadequate and employees must be removed from the job 
if expectations are not met (as to behavior). 
We concur with HCFA that employees should be expected to conform to prescribed 
behavioral requirements. However, if staff suspected of abuse are retained, additinal 
training, counseling, and monitoring should be required.  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. 20005 
American Medical Directors Associatlbn 
12100 Blue Paper Way 
Columbia, Maryland 21044 
National Aging Resource Center on Elder Abuse 
Research and Demotistration 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 
1100 NE 125 Street 
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 
Rehabiltation Care Consultants, Inc.

6401 Odara Road 
Madison, Wisconsin 53719  APPENDIX B

STATE ELDERLY OR NURSING HOME LAWS AND REGULATIONS 
nd regulations provided by respondents and

The following is a compilation of laws 

found in published abuse literature. The laws and regulations referenced are a

partial list in some States due to incomplete respondent reporting and recent

legislation or amendments.

Alabama 
Long Term Residential Health Care Recipient Ombudsman Act
, 1985.

Adult Protective Servce Act of 1976, (Acts 1977, No. 780, p. 1340 . Section 1).

Alaska 
Protection of the Elderly, Chapter 24, Section 47.24.010, 1983. 
Offce of Long-term Care Ombudsman, Chapter 24, Section 44.21. 
Arizona 
Adult Protective Servce Legislation, ARS 46-451, 452, 453, 454, and ARS 14-5310.01. (ARS 46-453 
and 454 enacted 1984; remainder, 1980) 
Arkansas 
Arkansas Statue 59-1301, Adult Abuse Statute, 1977, amended 1981. 
California 
Assembly Bil 1805 (Felando) Chapter 1184, Statutes of 1982.

Senate Bil 1210 (Carpnter) Chapter 1273, Statutes of 1983.

AB 238 (Papan) Chapter 
1164, Statutes of 1985.

AB 749, Chapter 25, Statutes of 1986
, effective 1987.

Colorado 
Disabled Adult Protective Servces
, 1983.

Licensure Standards, 1982, amendments 1986, 1988.

Connecticut 
CGS 17-135 a-m, 1977.

Protection of the Elderly Act
, 1978.
 Delaware 
Abus, Neglec or Mistreatment of Residents in Medical or Long-term Care Facilties, Senate Bil 
463, 198. 
Adult Protecive Servce Act, DE Coe Title 31, Chapter 39, 1982. 
District of Columbia 
Adult Protective Servce Act of 1984, DC Law 5-158. 
Rorida 
Adult Protecive Servce Act, Setion 415.101-113, Florida Statutes, 1987. 
Nursing Home Residents Rights, Setion 40.022, Florida Statutes. 
Long-term Care Ombudsman Act, Setion 40.301, Florida Statutes. 
Georl!ia 
Long-term Care Facility Resident Abuse Reporting Act of 1980, O.  , 31 80. 
Bil of Rights for Residents of Long-term Care Facilities of 1981, O.  , 3 100. 
Disabled Adults Protecion Act of 1981, O.  A, 30
Domestic Violence Act of 1981, O.  A, 19-13-1 et seq. 
Hawaii 
Hawaii Revi Statutes, Chapter 349C, Elder Abuse or Neglect, 1981. 
Idaho 
B. 1267, amended, Offce of Ombudsman. 
Elderly Abuse, Exloitation, Neglect, and Abandonment Reporting Act, Idaho Code, Chapter 52

Setion 39-5201 - 39-5212, 1982.

Idaho Coe, Chapter 28, Setions 2-734; 39-3301 - 39-3309, amendment 1983; 15- 101-502.

Ilinois 
Nursing Home Care Reform Act of 1979, PA 81-223, 1980, amended 1981 et al; PA 85-940, 1988.

Life Space Care Facilities Act, Public Act 82-547, 1982, amended PA 82-783, 1982.

The Domestic Violence Act.

Elder Abus Demonstration Act, amended 1984 by SB799, SB801.

Abus and Neglected Long-term Care Facilty Residents Reporting Act, P A 82-120, 1982, amended

PA 83-1530, 1985; PA 84-798, 1986; 1988.

Indiana 
Indiana Coe, PL 41- , Dept. of Human Servce, 4-28- 1 through 4-28- 3, 1987.

Indiana Coe 4-27- 1 et se., Adult Protective Servce, 1985.

Indiana Health Facilities Rules, 410 lAC 16.  , 1984.

Indiana Coe 4-285-1 et se., APS, 1987 (pL 42-1987).
 Iowa 
Iowa Coe, Chapter 235B, Adult Abuse Servce, 1983. 
Kansas 
Protection from Abus Act 1979. 
Reporting Abus or Neglec of Certain P rsons, KSA Chapter 39, Article 14, 1980, amended 1985. 
Abuse Care Homes - Unlawfl Acts, 1961.

Kentuckv

Protection of Adults Act, KRS 209, 1976, 1978, 1980.

Domestic Violence and Abuse Act, KRS Chapter 403, 715-785, 1984.

Louisiana

Louisiana Revise Statutes, Title 40, Act 687 of 1978.

Louisiana Revied Statutes, Title 14, Acts 519 and 551 of 1982 (Original APS Law), amended 1983

1985, 1987.

Louisiana Revise Statutes, Title 14, Act 850, 1981, amended 1987. 
Maine 
Adult Protecive Servce Act, 22 M.R.S.  , Setion 3470-3487, 1981. 
Domestic Violence Act, 19 M.R.S.A, Setion 761, 1979, amended 1983. 
Act to Establish the Main Probate Coe, 18A M.R.S.  , 1981. 
Marvland 
Abuse or Neglect of Vulnerable Adults, Article -Z7, Setion 35B, 1988 draft.

Health General Article, Title 19, amended 1983.

Adult Protecive Servce Act, Chapter 148, enacted 1977, amended 1985.

Massachusetts 
MA Patient Abus Statute (MGL Chapter 111-72 F-L), 1980.

Massachusetts' General Laws 19A S. 14-26 or Acts of 1982, Chapter 60, 1982.

SB 2206, Chapter 83-544, 1983.

Michie:an 
Act Number 519, Public Acts of 1982, 1983.

MGL, Chapter 265, Seion 13A, Assault & Battery.

Older Michigans Act, HB 4123, 1987.

Adult Protecive Servce, SB 223, 1982.

Michigan Health Coe Act 36, Public Acts of 1978, Section 20201.
 Minnesta 
Vulnerable Adults Act, Minnesota Statutes 626.557, Reporting of Maltreatment of Vulnerable Adults

enacted in 198, amended 1981, 1982, 1983, and 1985.

HF 36, Patient Bil of Rights, Chapter 248, 1983.

Missisippi 
Adult Protective Servce Act 
of 1982. 
Protection from Domestic Abuse Law
, 1981. 
Mississippi Vulnerable Adults Act of 1986. 
Missouri 
Protective Servce for Adults Act, RSMO 66.251, 1980 (Supp. 1981) et seq.

Omnibus Nursing Home Act, RSMO 198.001-198.186, amended 1979, 1987.

Institutional Servce Manual, Setion VII, 1988.

Institutional Servce Manual, Setion VII, 1988.

Division of Aging, 13 CSRI5.

Montana 
Montana Elder Abuse Prevention Act, 1983, amended 1985 (Title 53, Chapter 5), revised 1987 to 
make a secnd offense of elder abuse a felony. 
Nebraska 
The Offense Involving the Family Relation Law, 1979.

APS Act, 1988 (LB 463); Complaints (LB 235), 1983; Nurse Assistant (LB 273), 1983, (LB416), 1984

(LB 921), 1986.

Nevada 
The Abuse, Neglect, Exloitation of Older Persons Act, NRS 200.5091 et seq., 1981, amended 1983 
1985, 1987. 
New Hampshire 
Protecive Servce to Adults Law, RSA 161- , 1977, latest revision 1988. 
Patient' s Bil of Rights, RSA 151:21; Ombudsman Statute, RSA 126
New Jersev 
The Prevention of Domestic Violence Act, NJSA 2C:25-1 et seq., 1982.

Mandatory Reporting of Adult Abuse to the State Ombudsman Act, NJSA 52:270-2, PL 1983,

Chapter 43.

Enabling Legislation for the Offce of the Ombudsman for the Institutionalized Elderly, NJSA

52:270-1 to 16, Chapter 239, 1977.

Nursing Home Patients Bil of Rights, NJSA 30:13 to 11, PL 1976, Chapter 120, 1976.

Bording Home Residents Bil of Rights, NJSA 55:13 B-1, et aI., PL 1979, Chapter 500.
 New Mexico. 
Adult Protecive Servce Act, 1982. 
New York 
Patient Abus Reporting Law (public Health Law, Section 283-d), 1977, revied 1980). 
Adult Protective Servce Law, Article 9-B of the State Social Servce Law, includes section 473, 473
, and 473-b of the Soial Servce Law. Setion 473, 1975, amended in 1979; Section 473-a, 1981; 
and Setion 473- , 1984. 
Health Facility memoranda 80-53 and 80- , Patient Abuse Reporting. 
North Carolina

Protection of the Abused, Neglected, or Exloited Disabled Adult Act, 1973.

SB 18, Chapter 83-88, 1983.

SB 13, Chapter 83-143, 1983.

North Dakota

Bil of Rights for Health Care Facilty Residents, Chapter 50-10.

Long,-T eCrm Charea Opmbtudesmren , 5Cha7pte6r 5.0- 10.  , SL 1983, Chapter 524; SL 1985, Chapter 524; SL

1987
Ohio 
P1atie9nt Ri8ghts,6 Hea.lth -Safety-Morals 3721.10- , H60, 1979; H694, 1981.

Protective Servce for Adults Law, Section 5101.60-71 and 5101.99, 1981.  Amended Section 5105.61,

Crimes Procures, Re  rting, 2921.22, H28, 1980. 
Oklahoma 
Nursing Home Care Act, 1980.

Protecive Servce for the Elderly and Incapacitated Adults, enacted 1977, amended 1985, 1986.

Oregon 
Nursing Home Patient Bil of Rights, ORS 441.6 et aI, 1979, amended 1981, 1983, 1985, 1987.

Reporting of Abuse of Elderly Persons Act, ORS 410.6 et aI, 1981, amended 1983, 1987.

Patient Abuse Act, 1979.

Protective Servce, ORS Chapter 411, 1975, amended 1980, 1981.

Assault and Related Offenses, Chapter 163, 1971, amended 1975, 1977.

Intimidation, Chapter 166, 1981, amended 1983.

Criminal Mistreatment, Chapter 163, 1973, amended 1981.

Pennsylvania 
Older Adults Protective Servce Act, 
1979, 1987. 
Protection from Abus Act, PL 109, 1976.  ; :
Rhode Island 
An Act Relating to Elderly Persns, PL 009-1981, 1982.

Domestic Violence Law, 198.

Felony Act, Seion 11- , 198, amended PL 1981, PL 1988.

Department of Elderly Afairs Legislation, Chapter 66, 66. 1, and 66.  , amended 1985.

Abus in Health Care Facilities, Health and Safety, Chapter 17.  , PL 1987, PL 1988.

Regitration of Nursing Asistants, Health and Safety, Chapter 17.9, PL 1987, PL 1988.

South Carolina 
Protecive Servce for Developmentally Disabled and Senile Persons
, 1974.

Client- Patient rrotection Act (CPPA), 1979, amended 1984, 1986.

South Dakota

SDCL 28- , Public Welfare and Assistance, LS 1937, Chapter 220, Section 1.

SDCL 28-8-23, Title XX Soal Servce Program, SL 1975, Chapter 188, 1975.

An Act to Prohibit Abuse of Disabled Adults, SB 292
, 1986.

Tennesse

Protective Servce for Elderly Persons Act, 1974, repealed 1980.

Adult Protection Act, 1978, amended 1980, 1984
, 1986. 
Texas 
Chapter 48 - Title 2 - Human Resource Coe, passed as elderly protective law in 1981 and amended 
to include disbled adults in 1983. 
Utah 
Adult Protective Servce Act, 1977, amended 1983. 
Vermont 
, 1987.

Report of Abuse, Neglec and Exloitation of Elderly and Disabled Adults, Title 18, Chapter 22 
amended 1983, 1985, 1986
Abuse Prevention Law, Domestic Violence Law, Title 15, Chapter 21, 1979, amended 1981.

Vir2inia 
Public Servce Laws, Chapter 1, Setion 63.  55. 1 through 63.  55.7, and Chapter 24, Section 2.  373
through 2.  373. 
Washinf!on 
RCW 70. 124, Nursing Home Reporting Law
, 1983. 
RCW 74.34, Abuse of Vulnerable Adults Act, 1984.  West Virginia 
Soal Servce for Adults, Chapter 9, Aricle 6, 1981, amended 1984. 
Prevention of Domestic Violence, Chapter 48, Article 2A 
Wisconsin 
The 1983 Wisnsin Act 398, 1984.

Crimes and Boily Serity, Setion 940.28'-29 , 1975, amended 1977, 1979, 1981, 1985.

Administration Coe HSS 132.43, 1982; HSS 132.  , 1982, amended 1987; HSS 132.6, 1982, amended

1983, 1987.

Wvomine: 
Adult Protecive Servce Act, 35-20-101 to 35-20-109, 1981.  ' .
. '
... ...
APPENDIX C

DEGREE OF NURSING HOME ABUSE REPORTING

Degree of 
PERCENT OF 
RESPONDENTS  Reporting 
100%  100% 
90%  90% 
AL WAYS 
80%  80% 
70%  66%,  70% 
60%  60% 
USUALL Y 
50%  4 7%  50% 
400/
40%  37%  36% co;;;;  38%  37%  40%  1//:://1 
30% 
30%	 SOMETI 
20%	 20% 
13% 
10%	 10% 
RAREL Y

ALL 
EMERGENCY
NURSING HOME  ATTENDING 
ROOM 
STAFF  PHYSICIANS 
REPORTERS  PHYSICIANS  Sometimes to
I I
 Rarely Report

SPECIFIC REPORTERS 
Graph Interpretation:	 Respondents were asked four questions related to 
reporting. First, how often is abuse reported in general 
by any possible reporter (All reporters). Second, how 
often is abuse reported by nursing home staff as 

subgroup of all reporters. Thirdly, how often is abuse 
reported by attending physicians. And finally, how often 
is abuse reported by ER physicians. 
percent of 
an example
As  , for nursing home staff: 	 13
respondents believe staff always report abuse, 36% 
believe staff usually report abuse on.
, and  so  APPENDIX D

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 Offce of Human Development Servces 
and the Administration on Aging. The full texts of their comments are attached. 
'111  &. 
DEPARTMENT OF HEALTH  HUMAN SERVICES	 OHice of the Secretary 
'''''41'	 Washington, D.C. 20 
MEMORADUM  DEC 2 9 1989 
TO:	 Richard Kusserow 
Inspector GQenernal s
FROM:	 Arnold R. 
Acting Ass  'ta  for Planning and Evaluation 
SUBJECT:  OIG Draft Reports: (1) "Re ident Abuse in Nursing 
" and 
Homes : Respondent Perceptions of Issues (2) 
Resident Abuse in Nursing Homes : Resolving Physical
Abuse Complaints" 
I commend the OIG staff for producing two excellent reports 
documenting the problem of resident abuse iitn.  nursing homes and 
recommending strategies for dealing with  OASPE supports the
orG' 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 &. HUMAN SERVICES  . Financing Administration 
0- ---.-----

Memorandum 
"10 
Date 
If 
From 
Re 
OIG Drft RerPt:e Roeinde nt Ab in Nuin Ha: 
(1) 
Subject  of Iss-a-Q6-SS-00360,
(2) :Rlvin  Ab 
lbysica  Calai-a-Q6-SS-000361 
Inr 
'!e 
th 
Office of 
re  cc 
rerr 
rerWrte. ea rF  ir,  ditgo yr o  sfort   on th tw sujec
we Rerrw ith yo  methodolog, pacuarly
with  re  Peion of Iss st. Hcer,
genly agtro  the  'l 
tco uaa :lis thwe ith th  re.c,.h,.e,.rst.io nsr, aers mteu,s h  wae a dldoy  ubreer t hdoene
cotion 
Oc  of pacipatiroen,i ws hch wilrl bee i n effec until
th 
1, -1990. On tht date  whch cotain may
of  re",, 
th safeg  \byo dOI G in  wil gaodtiona
effec. We do oo beieve it  be awrcriate to DB 
d1es at th ti. 
iWne ibeeiweve  airt  wod be adisle to inud mrue si no:tchti osn ta.bt
tahpe p  ino:rtipon rgcat herin p  in  th
the data gatherin  wa an opinoan snuey , rather 
's!ci etnteif icatoly p collerd  c th rreiewe. tst hfoYe ut ;t hie.  dea.t,a  we preatre as fact.
ab 
oreffirceiatlsic nw hcn iun einsg batae   quon thi ts ies ai oprucle mof,  twhh ef ithnoss. 
:rtion 
CX  on th spific  ar attd1. Plea 
advis us whth yoo agr with an poition at yo ealies 
COenen. 
Attd1  O:ts 
of th Heth Care Financing Mnstration (lCA) 
Abe in 
on eIG Draft AudiPt eR r rt on Resident  Nursing
Ha: Resent  ion of Issues--(Qa-06-88-00360) 
Reccmation 
No. la 
rrsr 
HCA shod reqire  traing regations,
as part tofh i ts nurse aide 
ongoing traig cocerng  aging procs an  htoa c ope with
and avoid corondtactixonta l situation. E\rtr, th nursing  shod 
ale 
be reqired to  staff tprariogr easn  unearlseta ing of  and
reporting resibilities an  for  incidents. 
O:ts 
HCA 
ths 
We agree with  recation an  actively workig to 
Aimclt e(tmhte  Aitc.)  rSeqeiiroe nth C18 1S9 (Cef) t(a2 )  atnoh  ave1e 91s9 ib(e sf)h (2 )r oefa tthi oSoni aflo rS setartiety
nurse aide traing0 amn    evaluation procm. Seion 
th 
aJge Recciliation .A of  (CE 
r69e0q1(ibr)e s( 2t)h otf  th Sereta issue proped regation 198n9u  e  89)
catecy  on  enaidce tt.
traing an  evaluation 
procm with 90 dayst ohf  traig
Secion 6901 (b) (3) of OsBk 8i9,  m:ifier th OJria.un for  rrta
include "baic nursing  person cae ski, rection of 
hbeaaicth r easnto sroactiiavle  sseervrivciec en, ea,n  rcesaid eonft sc' oritgihvtse.l y imlr:eedv r etihdetnts,
the  .. we 
imlemrteactioant ioof n.  sttutoroy .atlliyal un reqrerts wil fufil
eIG'  caHo:tA   isc  ert  workig to iscsouet etht  prtohe dfin 
rues. Althgh we  thbte  th  of th preise  of 
wil 
rues, we tcha  absesu e ycu  ca  provide for procm tht
encorage  :fsible 
for residents. 
Recation 
III  No. 1b 
rerats 
Iii  lCA shod reqireh, aas  pa of th a:sion  for a ne
resident, nuing  to provide gudance to reidents corng th
ha 
difference in living in a nuing  enviramt, J:sible probler
they may encater an ways to dea with such probler. 
O:ts 
H:A 
We believe th recation is addresed in Feeral reation at 42 
er 483.1t0 hwthi ch are to be effecive O=ber 1, 1990. Thi proision
reqires  thir 
residents be notified of  rights an service. 
Recdation 
No. Ic 
HCA shod reqire, as pa  coition 
ha, stff resibolfe  its  of participation for
nursing  for survising or traing dire care
staff to acqire 
skil necsar to effecively train an survise 
paraprofessional and nonprofessioo stff. 
: I
 Page 2

o:ts 
H:A 
be 
Ween a.g ree with th  thr encullee nation an have  acively p.rsing ths
regatAiso pnar tr rotfi oo  a,i dthe t raing an CGtecy evaluation progran
Seretary is reqired to esablish
in la
regation for th qualfication of intructcrsa otf  nue aide traing
and c:tecy evaluation progCl. Whem we  i  predict th preitshee 
cotent of th fin rues, thre wil be  qualification for 
tht  ITt 
intructrs. Alo, s4t2f e m 483. 30 indicates  facilities " have
sufficient ntuhi nhgi gh  to provide nursing an relate service to attain 
practicale physica, meta, an pschocial
or maintain  deterr 
well-being of each resident as  by reident assessrt plan an
II This wod 
individual cae plan.  include th survisory nursing staff
having th necsar skil  direc cae staf in a maer 
to supervise  th 
reident rights, inluding 
consistent with  right to be free fran
abe . 
Reccmation No.

fur 
coct 
cocerng 
H:A shcd  research  long term cae fXlicies
wrahtiicohs p nraerctes asrt ftfo  sctcitrloilt ys traens sp raon,i adeb efo.r  adeqate stff-patient
O:ts 
H:A  IT 
we beieve tht we hae alreay develop an approriate  for 
enring tht facrileitsiees  have adeqate an appropriate staff.
metioned in oor  to Rt:lIlenation lc, KFA wil reqre tht 
suficient staff to proide for 
facilities have  th nees of
hoer, it 
residents,  is clea tht increing stf-rreeidreantr tr atios 
alone wil nmot cao trol abe. Th ootcoriente  gives
facilities  flexibility in determg. th ways th wil proide
for staff staility an ene tht th 
rrt. We alo note tht any furtr resenarecehs  ina nt hrsig ahtrse ao fw roedsi rdeenqtsr eare 
additional fuing.  CCts 
of th Heth Care FinC  Mnistration (H:A) 
th  rt - Resident  Ha: 
on 
e in Nursing 
ResoOlIvG iDnrafgt  Phyi Abe Oalaints--(QA-06-88-00361) 
recs 
coition 
OIG  tht H:bA,a a,s  part of its  of participation for
hospitals an nursing  shod: 
Recation No.

al 
Reqire  nursing ha stf an hospita 
al sued  rre:Uca personel to report

abe to th 
loc  enoinrcciedetn tas nof   nursing ha adrraetiborility
law  to th cetral agcy assigned 
ahe CClaits. 
for resolution of 
CCts 
H:A 
ths r wil rere,
We do not agree entirely with  eccullenation. We  ha), tht al
effecive O:ber 
ahe  1, 1990, at 42 c: 483.13 (for nursing 
aleged  be reJ;rt to th nuing ha adrator or othr
official in accrdan with state law. H:A hoita coition
th  O:sion  Hetbre
participation santa  rsJ oint  on Acreditation of 
Organzation  ahe. Hcer, 
hospita coition  do not reqire rerperqtirneg  t.hoft  hoita  the
sartnae tdeo  l naowt .b Weiee aver  wneoo ftn  paaewr tetioc oi rpfea atvi isosnei g dcnou f iccaoti taiobne  porf.o blem in hfololCiMtas
do not beieve tthat .t h OIG ha dertrate a signicpaati cpiropbalteimo nwi.t hWe
to hai 
e:CCIlIl  ation No. 
ha 
Reqire nursing  to aregprt  al ahe inidents to loc 
enorcat, th  reibilty  law
cetral 
,I. iI 
 th  assigned  forA resgol.u tion of 
abe calaits an to  state SUey an Certification 
CCts 
H:A 
fuy  Ag, 
i jl  Wcec dbo enrot  agree  wwiilt hr etqhi rer ethcta tail oanle.g ed inceeff eocifv aehe
1, 1990, we 
report 
to th nuing ha adratotrh  
or outside official in 
aacbcred ainnccei dweintths  sctaa te law. We beiehvea ed  ist shu faicdiernat aton rt hwt imtihotr
veber te ffeciveleyn  orcatb y 
the nee for invol 
of law  personel. 
Recation No.
 su 
ha 
Reqire nursing  to matain report of  inidents of ahe 
an  th nuing ha. 
the action taen by 
CCts 
H:A 
reire tht nuing
Whe aargr ece oancdt b eieve tht th DS regation, which 
investigation of aleged 
abe, matain evidence of
invesigatiorne, aant tiaoen co.r recive action wh abe is verified, wil
ths 
satisfy  Page 2

Recation 
No. 4 
Reqire aCstrators to coct anysis of al incident reprt
determe imlication an appropriate acion. 
O:ts 
lCA 
th 
th  regation 
We agree an beieve tht  new  cover  issue. 
Recation No.

ha 
Reqre nursing  to spify, as pa of th nursing ha residents 
ahe of  eithr rrtaly
polra np ohfs cicaraey,  au npllaen  ttoo  pprreovetnet  hiherseal f.r eident who is 
O:ts 
HCA 
We agree an believe tht th new reation cor ths issue. The
regation 
CCrehive assessrt an
at 42 CE 483.20 proide for a 
developt of a plan of care for every resident. Th plan assessrt an
plan of care shwd  spial 
inclaudhe ea,n yi f nasarers.i dent nees, inuding spific 
steps for prevention of 
Recation No.

su 
ha 
rrtoring an caeling

Reqre nuing 
to proide ongoing 
anloyee  of ahing residents. 
O:ts 
HCA 
su 
th 
We disagree with  t:Ulenation. Coeling cad be ineqate, an 
beieve  of ahe shwd be alCM to
we do not  tht person 
cotine  whe  caeled.  bevior 
to work with residents  rabeeindg   Tihfe ier  xtion 
nut be appropriate or th nu be  fran th job 
are not net. 
Recations 
Oter 
th recation  loc 
HCA agree with  for state an  re5nsibili ties
resolution an follCMp tht reqres each state to matain retrievable
data for lCA.

agr 
Itnh a Adddititorna, tHio:An  alo  with tch ajoi nt !  lIlIendation tht lCA and

ahe  al  on Aging develop  pd.eefisnt.i on an categories of
for  state an Feeral reprting  wil 
We  work 
ths en.
 .. 
".wee,.. 
Office of 
DEPARTMENT OF HEALTH &. HUMAN SERVICES	 Human Development ServICeS 
A,;sistant Secretary 
Wasbinaton 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 H mes. We -concur with the draft

reports. 
If you have any questions, please contact Deborah Bass at

245-3176. 
J:t  + " &. 
"V"" ' 
DEPARTMENT OF HEALTH  HUMAN SERVICES  OffiO of the Secretary

Washington, D.C. 20201

Administration on Aging 
Kusserow 
TO:  Richard po
Inspector General 
Acting Commissioner on Aging 
FROM: 
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 "
Abuse in Nursing Homes: Respondent perceptions of Issues
and " Resident Abuse in Nursing Homes: Resolving Physical 
We are pleased that the current draft

Abuse Complaints 0 
reports incorporate changes which respond to most of the

concerns that AoA expressed about the earlier draft

materials 0 We want to thank George Grob for his time and 
diligence in making the necessary changes 
addressed, we continue

While most of our comments have been 

to have serious concerns about one major item in the report

The Executive

on Resolving physical Abuse Complaints 

Summary (po iii) under Recommendations relating to Federal 
among other things, that the

Responsibili ties proposes, 
Administration 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

The report goes on to state that,

specific problem areas 0  (p 0 18), there are no 
for several reasons which are cited 

adequate national nursing home abuse statistics to provid

an incidence rate or trend for nursing home abuse 

We concur with the observation that there are no data which

or trend regarding

can be used to provide an incidence rate

The impediments to the collection of

nursing home abuse  ty of

such data which the report cites are beyond the capaci 

Therefore, it is not possible for AoA to

AoA to overcome 
s recommendation to expand and

respond to the report' 
strengthen its efforts to issue periodic public reports

s own 
concerning abuse trends  In light of the report' 
conclusions regarding the significant nature of impediments

data, we once again request that

to the collection of tren  - 2

the recommendation concerning AoA which appears on 

p. iii

the Executive 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 deali  resident abuse, 
ng wi th  2) promote
public awareness and education concerning abuse occuring 
in nursing homes and 
3) promote use of volunteer
Ombudsman in nursing homes. 
Again, we appreciate 
the opportuni ty to review and comment

on the draft reports 
prepared by OIG.
 , "
APPENDIX E 
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 
Additional comments were received from a select representation of State and local 
entities involved directly or indirectly with issues relating to the elderly, nursing 
homes, or law enforcement. All comments were reviewed and 
analyzed. Findings 
and recommendations in both reports' reflect many of the pertinent concerns and 
issues raised by the commentors on the draft reports. 
The following are short excerpts expressing concerns and observations of report 
reviewers: 
I am disturbed by the absence of national and state statistics in (the) two-part report and 
(the) reliance on the impressions of a small sample of individuals with a skewed view of the 
issue. I am further disturbed by your failure to adequately define the term  abuse," which has 
resulted in confused and unreliable findings." (Nursing Home Advocate) 
MFCUs are required by law to review complaints only in Health Care Facilties that recive 
Medicaid funds and therefore may not even see a large number of complaints.  (State 
MFCU) 
"Tere should be a requirement for confidentiality in both the investigative and prosecutorial 
components. Information should not be released to the public until due proces 
has been 
concluded.  (State Complaint Cordinator) 
The subject of due-procs is n  t fully explored. An individual who is charged with the 
proc 
patient abuse must have an opportunity to clear their name. This  is very time 
consuming and expnsive. Suffcient attention has not ben focused in this area and it must 
be considered more fully." (State Complaint Coordinator) 
All persons employed on a status such as aides, cleaning personnel, support peple, etc., be 
required to be fingerprinted and their applications be sent to the FBI." (Lw Enforcement) 
Law enforcemenct aage ncies normally only find out about the caes after the fact. A death or 
injury. In many  the nursing home has a opportunity to destroy 
evidence to prevent 
publicity, to avoid lawsuits, et al. This would really mean that state and county health 
department would be the agencies who would be the enforcement arm." (Lw Enforcement)  APPENDIX F

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