RESIDENT ABUSE IN NURSING HOMES 

UNDERSTANDING AND PREVENTNG ABUSE 

Richard P. Kusserow


INSPECTOR GENERAL


OEI-06-88-0060 

APRIL 1990

, 

EXECUTIVE SUMMARY 

PURPOSE AND BACKGROUND 

The GIG conducted this study to promote a better understanding of abuse in nursing homes. This is the first of two reports. It examines the nature of abuse and ways to prevent it. The second report Resident Abuse in Nursing Homes: Resolving Physical Abuse Complaints examines existing processes for resolving physical abuse 

complaints. Both reports reflect the experiences and perceptions of knowledgeable individuals who 1) play some part, directly or indirectly, in the resolution of abuse complaints, or 2) have an interest in nursing home or elder issues. 

Abuse of the elderly is not a new phenomenon. Research findings and 

Congressional hearings of the 1970s and 1980s helped to increase. public awareness of elder abuse. However, little research has focused on the issue of abuse of nursing home residents; certainly, no national survey has been initiated. Existing studies of abuse focus primarily on family members and caregivers in their homes. Research indicates from 1 to 10 percent of the non-institutionalized elperly population may be 

subject to abuse.


While there are no exact statistics on institutional abuse, any abuse is unacceptable. Each incident major' or 'minor,' may be a terrifying experience and a significant breakdown in the responsibilty of government to assure a safe and caring environment for elderly and disabled individuals. The price for abuse is measured in 

the physical and psychological harm to the resident as well as by the economic costs of treating the abused resident. 

METHODOLOGY 

The term abuse covers many problem areas for nursing home residents ranging from 

environmental conditions needing correction to actual mistreatment of residents. 

purposes of this study, abuse is defined as mistreatment or neglect of nursing homeFor 

residents encompassing the following seven categories: 

Physical abuse 

Misuse of restraints 

Verbal/emotional abuse 

Physical neglect 

Medical neglect 

Verbal/emotional neglect 

Personal property abuse 
Since national abuse statitics are not available and states vary in how they define and 

collect statistics, we decided to survey knowledgeable individuals involved directly or 

indirectly with nursing home care. 
 Specifically, the inspection relied on 232 intervews 

with respondents representing State, Federal and national organizations which are 

either 1) involved with receiving, investigating and/or resolving nursing home abuse 

complaints, or 2) knowledgeable and concerned about nursing home or elder issues. 

A minimum of three principal entities were intervewed in each of the 35 sample 

States: (1) State Ombudsman, (2) investigator or director of State Medicaid Fraud 

Control Unit (MFCU), or legal counterpart where no MFCU exists, and (3) State 

nursing home complaint coordinator (the nursing home administrators' primary 

contact for abuse complaints). These entities were selected because our 

pre inspection indicated they were the most often involved in nursing home abuse 

complaint receipt and resolution in most States. 

Respondents, based on their functional expertise and knowledge, answered a wide 

range of questions about different aspects of abuse in nursing homes including their 

perceptions of the prevalence and severity of the seven abuse categories listed above. 

The experiences and perceptions of the participants coupled with a review of State 

and Federal policies provide the basis for the findings and recommendations of this 

report. 

MAJOR FINDINGS 

Nearly all respondents indicate abuse is a problem in nursing homes. 

Respondents differ, however, regarding the severity of the problem. A majority 

of the State oversight agencies and resident advocates for nursing homes perceive 

abuse as a serious problem, while many nursing home administrators and industry 

representatives perceive the problem as minor. 

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

perceived as the most prevalent forms of abuse.


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

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

categories of abuse except medical neglect. 

Respondents believe nursing home staff lack training to handle some stressful 

situations. 

Most respondents believe staff certification and training will help to deter 

resident abuse.

Administrative or management factors also contribute to nursing home resident 

abuse (e. , inadequate supervsion of staff, high staff turnover, low staff to resident ratios). 

RECOMMENDATIONS 

Because this inspection indicates abuse may be a problem for nursing home residents, we recommend the following: 

The Health Care Financing Administration (HCF A) should: 

Require, as part of its nurse aide training regulations, ongoing training concerning the aging process and mechanisms to cope with and avoid confrontational situations. Further, nursing homes should be required to document staff training and understanding of abuse and reporting responsibilities and procedures for abuse incidents. 

Require, as part of the admission requirements for a new resident nursing homes to inform residents about differences between living in a nursing home environment vs. living at home, possible problems they may encounter, and ways to deal with such problems. 

Require, as part of its conditions of participation for nursing homes 

supervsory and training staff to acquire skills necessary to effectively train and supervise paraprofessional and nonprofessional staff. 

The HCFA should further support research concerning long term care

policies which promote staff stabilty and provide for adequate staff-to­ patient ratios necessary to control stress and abuse. 

The Administration on Aging (AoA) should collect and disseminate 

information about nursing home practices which avoid stress and abuse 

and promote staff stabilty and adequate supervision. 
DEPARTMENTAL COMMENT 

This report has been modified to reflect many of the comments received from within 

and outside the Department of Health and Human Servces. Comments from the 

Assistant Secretary for Planning and Evaluation, the Office of Human Development 

Servces, the AoA, and HCFA are included in the appendix to the report. They 

generally agreed with our findings and recommendations. The HCFA indicates it has 

already done much to accomplish the recommended changes. 
TABLE OF CONTENTS


Pag 

EXECUTE SUMMARY


INTODUCTION


Purpose


Background


Scope and Methodology


FINDINGS 

Nearly all respondents indicate abuse is a problem in nursing homes. 

Respondents differ, however, regarding the severit of the problem. A majorit
 of the State oversight agencies and resident advocates for nursing homes


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


and industry representatives perceive the problem as minor.


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


are perceived as the most prevalent forms of abuse.


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


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


all categories of abuse except medical neglect. 

Respondents believe nursing home staff lack training to handle some stressful 

situations. 

Most respondents believe staff certification and training wil help to deter 

resident abuse. 

Administrative or management factors also contribute to nursing home resident


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


RECOMMENDATIONS 

DEPARTMENTAL COMMENTS 

APPENDICES 

Appendix A. National Organization Respondents


Appendix B. Tables I-VII: Respondent Perceptions


on Abuse Categories as Problems


Appendix C. Departmental Comments


Appendix D. Public Comments


Appendix E. Bibliography

.. .... ..

ACTUAL AND PROJECTED GROWTH OF THE ELDERLY 

POLATION (65 YEARS OLD) 

NUMBER (IN MILUONS) 

PERCEN OF POPULATI 

20 -..-..-..-.. 

10 -.. 

1970 198 199 200 2010 2020 YEAR &O aR POT1 RES NO. 81 

us CE BlU 

NUMBER (IN MILLIONS) 

PERCENT OF POULATION 

FIGURE 1 

PROJECTION OF THE NURSING HOME POPULATION 

65 YEAS AND OLER BY AGE GRP 

en 4 

lEas AND OVER


75 - 84 

065­

Z 0


198 1990 20 2010 2020 

YER 8O AG.- 118..1D "'AI 8Y u.s. 88'M AITIONAC II

AGUR 2

INTRODUCTION


PURPOSE 

The OIG conducted this study to promote a better understanding of abuse in nursing homes. This is the first of two reports. It examines the nature of abuse and ways to prevent it. The second report Resident Abuse in Nursing Homes: Resolving Physical Abuse Complaints examines existing processes for resolving physical abuse 

complaints. Both reports reflect the experiences and perceptions of knowledgeable individuals who 1) play some part, directly or indirectly, in the resolution of abuse complaints, or 2) have an interest in nursing home or elder issues. 

BACKGROUND 

Americans are living longer, and the nation s elderly population is growing at an unprecedented rate, partially as a result of new technologies and medical advances. There are now 28 miIion people aged 65 or older; by 2030, they wiI number more than 60 miIion, or 21.2 percent of the total population (figure, 1). As individuals live longer, their need for nursing home care may increase. 

While only about five percent of the elderly population are in nursing homes at any given time, it is likely the nursing home population wiII continue to grow rapidly the very old segment of the population continues to expand. Projections indicate 3. miIion elderly individuals will be living in nursing homes by 2030 (figure 2). The growth in the number of older people experiencing both disabilities and dependencies may place additional physical and emotional stress on both institutional 

and non-institutional caretakers. Persons advanced in age, limited by mental and/or physical impairments and dependent on others for their daily care, constitute the population most vulnerable to abuse. 

Abuse of the elderly is not a new phenomenon. Research findings and Congressional hearings of the 1970s and 1980s have helped to increase public 

awareness of elder abuse. Existing studies of abuse have focused primarily on family members and caregivers in their own homes. Research indicates from 1 to 10 

percent of the non-institutionalized elderly may be subjected to abuse. The incidence of and facts concerning institutional resident abuse are less known. 

Doty and Sullvan (1983) note that both Federal and State sources report receipt of incidents of resident abuse each year. Monk, Kaye, and Litwn (1984) found that State Long-Term Care Ombudsmen receive many complaints about nursing home 
, 

staff treatment of residents. Further, they note a substantial amount of maltreatment 

is never reported. 

PiIemer and Moore (1988) provide one random survey designed to assess the scope 

and nature of physical and psychological abuse in nursing homes. They found that 36 

percent of the sampled nurses and nurse aides had seen at least 1 incident of 

physical abuse in the preceding year; 10 percent reported they had committed 1 or 

more physically abusive acts. 

While there are no exact statistics on institutional abuse, any abuse is unacceptable. 

Each incident major' or ' minor,' may be a terrifyng experience and a significant 

breakdown in the responsibilty of government to assure a safe and caring 

environment for elderly and disabled individuals. The price for abuse is measured in 

the physical and psychological harm to the resident as well as by the economic costs 

of treating the abused resident. 

Federal Roles 

Three Department of Health and Human Services (HHS) agencies have either direct 

or indirect involvement with nursing homes and servces to residents of nursing 

homes: the Office of Human Development Servces/Administration on Aging 

(OHDS/AoA), the Health Care Financing Administration (HCFA), and the Office 

Inspector General (OIG). 

Administration on Aging 

The Administration on Aging (AoA) of OHDS is the primary Federal agency 

responsible for the State Long-Term Care Ombudsman (hereafter referred to as 

State Ombudsman) program. It further serves as the visible advocate for the elderly 

within HHS. The AoA meets the needs of the elderly mainly through a program of 

grants to State Agencies on Aging under Title III of the Older Americans Act 

(OAA) (as amended (42 D. C. 3001 et seq.)). Title III also authorizes activities for 

the prevention of elder abuse. The Act requires each State Agency on Aging to 

establish and operate a State Ombudsman program to receive and review complaints 

concerning nursing home residents. 

Health Care. Financing Administration


The HCFA administers Medicare and Medicaid program operations. Within HCFA, 

the Health Standards and Quality Bureau (HSQ) has oversight responsibilty for 

Medicare and Medicaid nursing home standards of care designed in part to ensure 

an environment free from abuse. To meet this obligation, HCF A develops and 

administers the regulatory requirements for nursing homes participating in either 

Medicare or Medicaid, develops training requirements for surveyors who conduct 
nursing home inspections, conducts yearly compliance surveys of five percent of those 

facilities previously surveyed by the State, and monitors State compliance surveys for 

quality assurance. 

The HCF A may directly receive complaints of abuse involving nursing home residents. However, these wil usually be referred to the applicable State agency for nursing home certification unless the allegation involves an "immediate and serious 

threat" to patient health and safety. 

Office of Inspector General 

Through Public Law (P.L.) 94-505, enacted in 1976, the OIG was established as an 

independent unit in HHS with the authority to prevent and detect fraud and abuse in Department programs. The OIG is required to 1) recommend policies for the detection and prevention of fraud and abuse within programs and operations administered or financed by the Department and 2) conduct, supervise, or coordinate investigations related to such fraud and abuse. 

Under Section 1128 of the Social Security Act, the OIG was provided authority to impose sanctions against health care providers convicted of Medicare or Medicaid 

offenses or suspended or excluded or otherwise legally or administratively sanctioned by appropriate State entities. In meeting this statutory authority, the OIG works 

with other Federal, State, and local governmental agencies and nongovernmental entities. As a further part of this authority, the OIG/Office of Investigations (01) has oversight of and grant certification responsibility for State Medicaid Fraud 

Control Units (MFCUs). 

The Medicare and Medicaid Patient and Program Protection Act of 1987 amends 

titles XI, XVIII, and XIX of the Social Security Act to protect beneficiaries from 

unfit health care practitioners. The Act states that if an individual is convicted of 

patient abuse in connection with the delivery of a health care item or service 

exclusion from the Medicare and Medicaid programs is mandatory. 

In September of 1986, the OIG/OI published an "Investigative Guide for the Detection of Patient Abuse." The guide was made available to State MFCUs for 

training and reference purposes. 

Existing Nursing Home Requirements 

The Medicare and Medicaid programs traditionally have used a condition of 

participation (COP) format to define requirements which must be met by facilties in order to participate in the programs. This format is based on the principle that each condition level statement would be a statutory requirement while standard level 

statements would be lesser requirements within a condition. 
Under current law, a skiIed nursing facility (SNF) must meet COPs to participate in 

the Medicare or Medicaid programs; intermediate care facilties (ICFs) must meet 

standards. Current COPs and standards were originally published in 1974. The 

SNFs have a single uniform definition which extends the same level of care 

requirements to both Medicaid and Medicare programs. The ICF benefit was 

intended to allow facilties which did not meet SNF COPs to participate as ICFs and 

provide health-related care, not at the skilled level, to Medicaid patients. 

Provisions for resident rights are ambiguous and enforcement is difficult because a 

resident's rights and a facility s obligations are sometimes unclear. Recognizing that 

a resident s rights, living conditions, and medical care are essential components of the 

quality of life in a facilty, HCF A developed outcome oriented survey instruments in 

June 1988. The emphasis of current regulations is on process, not outcomes of that 

process as is relates to residents. The regulations do not contain any SNF COP or 

ICF standard for a resident assessment. Also, there is no quality of care COP 

utilzing resident care outcomes, especially negative ones, to assess whether residents 

are receiving satisfactory care. 

Existing Medicare COPs are located at 42 CFR, Part 405, Subpart K and implement 

Section 1861U) of the Social Security Act. Current Medicaid standards are in 42 

CFR, Part 442, Subparts D, E, and F. 

Omnibus Budget Reconcilation Act of 1987 (OBRA ' 87). P.L. 100-203 

On December 22, 1987, OBRA '87 was enacted. The law includes extensive 

revisions to the Medicare/Medicaid statutory requirements for nursing facilities. 

Nursing home reform provisions, to be implemented October 1, 1990, establish 

uniform requirements for Medicaid SNFs and ICFs. The law revises the conditions 

under which nursing homes may participate in the Medicaid/Medicare programs, the 

process for monitoring compliance with law, and the remedies available to Federal 

and State agencies in the event of noncompliance. It further expands nursing facilty 

resident rights to include freedom from 1) inappropriate use of physical or chemical 

restraints and 2) physical or mental abuse or punishment. 

The NF (any Medicare SNF or Medicaid facilty which is not an ICF for the 

mentally retarded) must inform residents orally and in writing . of their legal rights. 

The HCFA draft regulations provide all incidents of abuse be reported to the 

nursing home administrator of to any other agency designated by State law. 

Residents may fie a complaint concerning abuse or neglect with the State 

survey/certification agency. The NF must permit the State Ombudsmen access to the 

resident and the resident's clinical records with the permission of the resident or the 

resident s legal representative. 
The NFs wil be required to verify the competency of applicants prior to their employment as nurse aides. No nurse aide may be employed for more than four 

months unless the individual has completed State-approved training or successfully passed a competency test. Verification of a nurse aide s competency will be strengthened through the required use of a State maintained nurse aide registry. This registry will certify that the individual has met the required training requirements and indicate the documented findings, not limited to convictions, of resident abuse, neglect, or misappropriation of resident property involving an individual listed in the registry. If the State determines a nurse aide has been 

involved in these activities, the State wil, after notice and reasonable opportunity to rebut allegations in a hearing, notify the nurse aide and the nurse aide registry. 

State and Local Roles 

The primary responsibility for designing, operating, and coordinating services for the 

elderly lies with the States. Several State agencies may be responsible for resolving nursing home problems including: 

nursing home complaint coordinators 

State Ombudsmen (under the direction of the State Agency on Aging), MFCU or other legal authorities where no MFCU is established 

agencies for nursing home certification and licensure 

licensure agencies for medical personnel 

adult protective services, and 

local law enforcement. 

The nursing home complaint coordinator is the individual designated to nursing home administrators as the central State authority to receive complaints of mistreatment or neglect of nursing home residents. This individual may be in any number of State 

agencies or part of a designated complaint unit, but is usually a staff member of the State nursing home survey and certification agency. 

The State Agency on Aging, through the State Ombudsman, is required by the OAA: 

1) to establish procedures for maintaining a State-wide reporting system to collect and analyze data related to complaints and incidents; 

2) to monitor the development and implementation of Federal, State, and local laws, regulations, and policies with respect to long term care in the State; 

3) to provide public education on their activities and long term care issues; and 

4) to promote training and certification of ombudsman staff and volunteers. 
The MFCUs are also required to review "complaints alleging abuse or neglect of 

patients in health care facilties receiving payments under the State Medicaid plan. 

If the initial review indicates substantial potential for criminal prosecution, the unit 

shall investigate the complaint or refer it to an appropriate criminal investigative or 

prosecutive authority" (Social Security Act, section 1903(q)). At the time of this 

inspection, there were MFCUs in 38 States. Those States without a MFCU have 

agencies with parallel responsibilities 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). 

Since natinal abuse statistics are not available and States vary in how they define abuse 

and collect statitics, we decided to survey knowledgeable inividuals involved directly or 

indirectly with nursing home care. 
 Specifically, the inspection relied on 232 intervews 

with respondents representing State, national, and Federal organizations which are 

either 1) involved with receiving, investigating, and/or resolving abuse complaints 

involving nursing home residents, or 2) knowledgeable and concerned about nursing 

home or elder issues (e.g., State oversight agencies for nursing homes or advocates of 

the elderly or nursing homes). (See appendix A and figure 4 for summary 

information on respondents sampled.) . These individuals were identified through 

contacts with the regional HCFA offices as well as several State agencies (e.g., State 

Ombudsman and single State agency for Medicaid). 

A minimum of three principal entities were interviewed in each of 35 States: 1) State 

Ombudsman, 2) investigator or director of the State MFCU, or legal counterpart 

where no MFCU exists, and 3) State nursing home complaint coordinator (the 

nursing home administrators' primary contact for abuse complaints). These entities 

were selected because our pre inspection indicated they were the most often involved 

in nursing home abuse complaint receipt and resolution in most States. In 8 of the 

35 States, we intervewed additional individuals including nursing home 

administrators, nursing home and resident advocates, and medical professional 

licensure personnel. Figure 4 shows the 35 States from which respondents were 

selected. 
Participants, based on their practical expertise and knowledge, answered a wide 

range of questions, by telephone or in-person intervews, concerning different aspects of abuse in nursing homes including the prevalence and severity of the seven abuse categories. While the experiences and perceptions of the participants provide the basis for the findings and recommendations of this report, these findings appear consistent with the information and statistics available from the States and 

independent researchers. 
INSPECTION ABUSE DEFINITIONS 

ABUSE: Mistreatment or neglect of nursing home residents. 

Physical Abuse


Infliction of physical pain or injury.


Examples include individuals either 1) reacting inappropriately to a situation, such as pushing or slapping a resident 

or 2) intentionally doing bodily harm. 

Misuse of Restraints 

Chemical or physical control of a resident beyond physician s orders or not in 

accordance with accepted medical practice. 

Examples include staff failng to loosen the restraints within adequate time frames or attempting to cope with a 

resident' s behavior by inappropriate use of drugs. 

Verbal/Emotional Abuse


Infliction of mental/emotional suffering.


3. 

Examples include demeaning statements, harassment, threats, humilation or intimidation of the resident. 

Physical Nealect 

Disregard for necessities of daily living. 

Examples include failure to provide necessary food, clothing, clean linens or daily care of the resident' s necessities 

(e. , brushing a resident's hair, helping with a resident's bath). 

Medical Nealect


Lack of care for existing medical problems. 

Examples include ignoring a necessary special diet, not calling a physician when necessary, not being aware of the 

possible negative effects of medications, or not taking action on medical problems. 

Verbal Emotional Ne lect


Creating situations in which esteem is not fostered.


6. 

Examples include not considering a resident's wishes, restricting contact with family, friends or other residents, or more simply, ignoring the residents' need for verbal and emotional contact. 

Personal Propert Abuse ( Goods) 

Illegal or improper use of a resident's propert by another for personal gain. 

Examples include the theft of a resident's private television, false teeth, clothing or jewelry. 

FIGURE 3

..

RESPONDENT SAMPLE


35 States Contacted 

Alabama Louisiana New Mexico Alaska Maryland New York Arkansas Massachusetts North Dakota * California Michigan Ohio Colorado Minnesota Oklahoma * Connecticut Mississippi Pennsylvania Florida Missouri * South Carolina * Georgia Montana * Texas Idaho * Nebraska * Indiana Nevada * Washington

Wisconsin Illnois New Hampshire Wyoming * Kansas * New .Jersey 

. States with no Medicaid Fraud Control Unit 

* Statu Vlalted On81te 

SURVEY RESPONDENTS BY ROLE


Type of Respondent Number % of All 

Respondent 

State 

Complaint

Coordina tor 16% 

Survey and Certification

Surveyors 

MFCUs Or Counterpart 18% 

Professional Medical 

Licensure Boards 

Ombudsman 16% 

Resident Advocacy

Organizations 

Nursing Home

Industry 13% 

National Organizations 

Consumer. Industry and

Local Law Enforcement 

Federal 

HCFA 

OIG 

FIGURE 4

.. .... 

. ... ,.. .. ....... ..... ... . ... . .. ..... ,,, ... . ,..... , .. ,,..... .... .. . ... .. .. ...... ....... ..... ,,, ... ,.. . . ,..,.. . .. , .,,.. .. . ......... . ....... .......... ... ... .................. .. .... ..... .... . ... ... . ........ .. .... .. ....... ..... ... .. .... . . ... .... . .. ....... .. ....... ... ....... .. .. ,,,, ..... ... ............ .,. .

FINDINGS 

Near all resoo cae abuse is a prob nursinQ homes. 

In each of the seven abuse categories defined for this study, 95 percent or more of 

the respondents indicate abuse is a problem for nursing home residents. 

Additionally, for every abuse category, more respondents believe it is worsening 

rather than improving. Respondent perceptions of increasing abuse appear to be 

supported by statistics from several States. Eleven States responded to our request 

for abuse reports and/or complaints which occurred during 1987 and 1988 or 1988 

and 1989. Eight States reported increased abuse statistics, while two reported no 

increase, and only one reported a decrease. 

'" n. ...."... 

Perceht. Chaljg P8rted,il?q 

. .. n.


:Zj........................


..M ill 

$hiQQtgQ.. S6lih afqnQ 

Old h6hia,/..... 

Mi9hi9?h 

it Neyad.(( 

NewVotk\ 

These States reported receipt of 331 complaints 
 or reports of abuse during 1988. 

Respondent difer. however. reQardinQ the severi of the problem. A maiori of 

the Ste oversiQht aQees and resident advoces for nursinQ homes perceive 

abuse as a serious problem. while many nursinQ home administators and indust 

represntes percee th problem as minor.


Although an of the seven categories of abuse are seen as problems for residents 

respondents perceive varyng degrees of severity (major, moderate, minor) for each 

category. Figure 5 shows these varyng respondent perceptions as to problem 

severity. There is relative consistency among four main respondent types (State 

Oversight agencies and resident advocates - MFCU, Survey and Certification 
.: 

Complaint Coordinator and Ombudsman) while the nursing home industry 

respondents consistently report lower problem severity. Differences between the respondent views on problem severity may be the result of 1) job function, 2) more direct versus indirect contact with the residents or the provider community, or 3) more knowledge or understanding of the problems. See appendix B for further respondent perceptions concerning the seven abuse categories. 

NURSING HOME INDUSTRY RESPONDENTS LESS OFTEN PERCEIVE ABUSE


AS A SERIOUS PROBLEM THAN DO OTHER RESPONDENT TYPES


ABUSE CATEGORY 

(! PHYSICAL ABUSf


Wil 0.0 (g MISUSE OF RESTRAINTB

f- 2 ?-o VfRBAL/fMOTIONAL ABUSE

f- -- PHYBICAL NEGLECT


IIIDICAL NfGLfCT 0:(

o W l! VERBAL/EMOTIONAL NEGLECT


0. .: -­
 U) lZ PERBONAL PROPfRlY ABUSf il(/ 0

a: 

LL W 0. RESPONDENT TYPE o(/ 

fSTATf MfDICAID PRAUD
 il .: CONTROL UNIT (MFCU) U CD


ff BTATf SURVfY AHD 0. I- CERTIFICATION UNIT


STATf COMPLAINT COORDINATOR


STATE OMBUDSMAN


NURSING HOME INDUSTRY 

(NURINO HOME ADMINIBTRATORS

AHD INDUSTRV ADVOCATES) ABUSE CATEGORY 

FIGURE 5 

As is the case with perceptions of the severity of abuse categories, nursing home industry respondents often have a different view of the trend of abuse categories than do other tyes of respondents. As figure 6 shows, nursing home industry respondents tyically perceive physical abuse, physical neglect, misuse of restraints and medical neglect as improving or staying the same. 

On the other hand, State Ombudsmen and complaint coordinators tyically see these problems as worsening or staying the same for nursing home residents. An average of 49 percent of complaint coordinators and 41 percent of State Ombudsmen believe resident abuse problems are worsening. In contrast, 20 percent of the nursing home industry respondents see abuse problems as worsening. 
::

RESPONDENT PERCEPTIONS OF ABUSE TRENDS:


IS ABUSE IMPROVING, STAYING THE SAME OR GETTING WORSE


FOR NURSING HOME RESIDENTS?


PHYSICAL MISUSE OF VERBAL/EMOTIONAL ABUSE RESTRAINTS ABUSE 

46% 48'1 

19% 

11".1 

30% 27% 26'1 

39'1 39% 37% 38% 49%


54% 54% 47% 44%


PHYSICAL MEDICAL VERBAL/EMOTIONAL PERSONAL PROPERTY NEGLECT NEGLECT NEGLECT ABUSE 

43'1 

21% 

32% 32% 

42%40% 39'1 3B% 44% 50'1 

54% 56% 

KEY 

PERCENT OF 

TYPES OF RESPONDENTS RESPONDENTS 

SA VING 

" ABUSE IS IMPROVING eOI/PLAINT COORD. 

(STATE) (UPPER BARS) ST ATE Ol/BUDSI/AN 

ALL RESPONDENTS ABUSE IS STAYING THE SAME 

STATE SURVEYOR (MIDDLE BAR) 

STATE I/FeU 

ABUSE IS WORSENING 

NH INDUSTRY \l 

(LOWER BARS) 

FIGURE 6

Physical nealec. verbal and emoti ec. and verbal or emot.Q abuse are perceived as the most Dreva orms of abuse. 

To gain an indication of the order of occurrence of the seven abuse problems respondents were asked to rank the abuse categories in order of prevalence. Figure 7 arrays the median ranks according to prevalence. The problems at each level were ranked about equal (no discernible difference based on the median) in frequency by respondents. Because prevalence is . a factor in assessing the severity of a problem (major, moderate, minor, or no problem), the most prevalent problems are often believed to be the most serious for residents. 

RESPONDENT PERCEPTIONS OF RELATIVE 

PREVALENCE OF ABUSE CATEGORIES 

NURSING HOME INDUSTRY RESPONDENTS AGREE WITH THE RANKING ABOVE 

EXCEPT FOR PHYSICAL NEGLECT SOURCE: RESPONDENTS FROM AND PROPERTY ABUSE. PROPERTY


ON81TE 8T A TE8 ABUSE IS A LEVEL I PROBLEM WHILE PHYSICAL NEGLECT IS A LEVEL 3 

PROBLEM. 

FIGURE 7 
........... . .. ... ............ ....,... .....,.. ........ ......,... .....,......,... ... ..... ........... .... ................. .... .. .. . . .. ... ,.. .... ... ., , ,,......... ........ , ,,,. .... .... ....... .... .... .... ...... ... ........... .......... ...,,,. ........ . .. ....... ........ ,.,,,, ,... ,, . ... ,... ............ .... .. .......... . ....... . . .. , ., . ......... ... 

Since State nursing home abuse reporting laws tyically separate resident abuse into 

the broad categories of physical abuse and neglect of care, many State agencies 

designated to receive and investigate complaints were not able to provide statistics 

according to the specific abuse definitions used for this study. Five States provided 

statistics of reports/complaints based upon the broad categories of physical abuse and 

neglect. Three of the five States report neglect was the most common abuse 

reported in 1988 while two States report physical abuse as the most often reported. 

The percentage by State and tye of abuse is as follows: 

... ..... ... .. ... ..... .. n 

rcent rceht dse 

. n. .... .. 

Miont36 

M;:achlisetts.. 

NeW'((jrk 

Kansas)... 

17%/ 

9?%L 

Nursing home staf. medica personnel. other paent and familv or visitors all 

contbute to abuse. However. aides and orderlies are the primary abusers for all 

caegories of abus except medical nealec. 

Nurse aides and orderlies have the principal responsibilty for the daily care of 

nursing home residents. As the primary caregiver to nursing home residents, it is not 

surprising most respondents, regardless of the tye of respondent, say nursing home 

staff (specifically, direct care staff - aides and orderlies) are responsible for most 

incidents of abuse except medical neglect. As seen in figure 8, a significant number 

of respondents believe medical personnel, other patients and family or visitors 
 also

may be primary abusers of nursing home residents in one or more categories of 

abuse. 
PRIMARY ABUSER OF NURSING HOME RESIDENTS


ACCORDING TO RESPONDENTS


ABUSER 

II PROBLEM 

NURSING 

HOME 

STAFF 

MEDICAL 

PERSONNEL OTHER 

PATIENTS 

FAMILY OR 

VISITORS NURSING 

HOME 

PHYSICAL ABUSE 3 % 17 % 3 % 

STAFF 

ALL STAFF 

EXCLUDING 

MISUSE OF 

RESTRAINTS (56 o/ 48 % 1 % 2 % RNS. L VNS 

AND DOCTORS 

VERBAL/EMOTIONAL

ABUSE 7 % 13 % 10 % 

PHYSICAL NEGLECT 88 15 % 0 % 3 % MEDICAL 

PERSONNEL 

MEDICAL NEGLECT 25 % (0 1 % 3 % LICENSED 

NURSES AND 

VERBAL/EMOTIONAL

NEGLECT 84 % 6 % 2 % 21 % 

PHYSICIANS 

PERSONAL PROPERTY 

ABUSE 1 % 18 % 15 % 

RESPONDENTS = 206 

OPRIMARY ABUSER OF NURSING HOME RESIDENTS 

TOT AL PERCENT MAY EXCEED 100 PERCENT AS SOME RESPONDENTS 

GAVE MORE THAN ONE PRIMARY ABUSER IN A CATEGORY. 

Graph Interpretation: For example, in the case of physical abuse, 89 percent of respondents 

reported that nursing home staff are the primary abusers of nursing home 

residents. 

FIGURE 8 

As indicated in figure 9, statistics from New York clearly support the finding that 

most nursing home abuse complaints can be attributed to nursing home aides and 

orderlies. 
!!.

:,. .. ..... :;::;:::

Charges of Abuse by Title of Accused 

New York's Experience for 1988 

Title of Accused 

Nurse Aide/Orderly w ::"E :0f:' 7':' 595 1 . 20 Number of Charge 

962 Substantiated 

Charges 

442 

Physician 

Other Non-licensed. 2b 1


Administrator 6


Other f:f 

Family 

200 400 600 800 100 1200 1400 

Number of Charges 

Reports from the State Department of Health


Bureau of Longterm Care Services


FIGURE 9 

Respondent believe nursing home staff lack training to handle some stessl 

sitatons. 

Many factors contribute to the potential abuse of nursing home residents by staff. 

Figure 10 summarizes some of the factors which respondents believe contribute to 

abuse. 

Direct care nursing home staff frequently must cope with stressful situations. Many 

respondents indicate staff are inadequately trained to deal with the physical 

emotional, and psychological aspects of caring for the elderly and disabled. This may result in abuse as an immediate response to a stressful or confrontational situation. 
MANY FACTORS CONTRIBUTE TO ABUSE 

BY NURSING HOME STAFF


High

Stress 

Low Staff 

Ra tios 

Inadequa te

Supervision 

of Staff 

Lack of 

Skills 

Training 

Lack of 

Empa thy 

for Elderly 

Cultural 

Differences Staff 

Personal 

Problems 

High Staff

Turnover 

More 

Severely

"' Residents 

Job 

Frustr a tion 

SOURCE: SURVEY RESPONDENTS 

Abusive or 

Belligerent

Patient 

Low Wages 

FIGURE 
.. ...................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . , 

.................................... ........................... ......... . . .

As one respondent states Faced with heavier levels of care, such as residents with 

more debiltating diseases, frustrated staff take out their stress on the residents. 

Respondents believe staff training deficiencies include a lack of sufficient training in 

1) behavioral skills to cope with or defuse confrontational situations, and 2) stress 

management skills. Further, some respondents believe some staff lack empathy for 

the elderly because they lack the knowledge needed to understand problems of the 

elderly (e.g., Alzheimer s disease). 

Respondents cited many reasons for nursing home staff stress. Many respondents 

believe stress is caused by the reported increase in nursing home admissions of 

severely iI residents. This stress is related to the difficulties of caring for impaired 

and dependent residents who require help in many of the activities of daily living. 

According to the Senate Special Committee on Aging (figure 11), as many as 63 

percent of nursing home residents suffer disorientation or memory impairment, with 

47 percent suffering senilty or chronic organic brain syndrome. 

SELEOTED OHARAOTER I ST I os OF NURS I NO HOME RESI DENTS 85 YEARS AND OLDER (1 gSS) 

Characteristic Percent Affected 

Se x: 

Ma Ie 25. F ema Ie 74.


Patient Requires Help:
 Bat hi n Dressing 9 ..................................... 91 .
 77.

Getting 63. sin 9 To i let Room

Eat I ng In and Out of Bed ................... 62.
 40.


Difficulty With Bowel and/or Bladder Control 54.
 Disorientation or Memory Impairment .................. 62.
 Senile or Chronic Organic Brain Syndrome .... 47. 

SOURCE: gin g Ame r I c a (1 9 8 7 - 8 8 e d I t Ion)
 Pre par e d b y S e n ate S p e c I a I C omm I t tee
 and A dm I n 1st rat Ion 0 n Ag I n 9 

FIGURE 11 

Other factors which may add to the stress encountered by nursing home staff and 

residents include cultural differences between staff and residents, personal problems 

of staff or residents, and abusive or bellgerent residents. 
Most respondents believe staff certifcation and traininQ will help to deter resident 

abuse. 

The required content, format and duration of training vary widely among States, with 

most training concentrating on health and safety precautions (e. , lifting a resident 

fire prevention, evacuation procedures, sanitation). Most respondents cite the value 

of staff certification and training. 

Of all respondent types, the nursing home industry respondents (47 percent) were 

the least likely to report that training and certification would deter abuse. Reasons 

cited include: 1) present training and certification have not effectively deterred 

abuse; 2) training does not usually include stress management; 3) overwork resulting 

from understaffng is not affected; 4) inadequate salaries for hiring qualified 

personnel wiI not change; and 5) lack of professional supervsion is not corrected by 

existing certification. 

Administrative or manaQement factors also contribute to nursing home resident 

abuse (e.Q., inadeQuate superv staff. turnover, low staf to 

resident ratios). 

Inadequate supervision of staff, low staff to resident ratios, high staff turnover, and 

low wages are cited by some respondents as factors contributing to abuse of nursing 

home residents. As discussed previously, nurse aides spend more time providing 

residents necessary direct care than any other group of nursing home personnel. 

However, this group of employees has the highest rate of turnover, averaging 75 

percent annually, according to one study by Almquist and Bates (1980). Low wages 

and the absence of employee benefits, recognition, and opportunities for 

advancement may all contribute to job dissatisfaction and rapid turnover among 

nurse aides. 

Nurses experience many of the same problems confronting nurse aides. Additionally, 

nurses have an increasingly important role of supervising and training 

paraprofessional staff. Respondents, recognizing the nurses' problems in meeting. 

these responsibilities, say inadequate supervision of direct care staff contributes to 

abuse. Although responsible for much of the training and supervision of direct care 

staff, nurses often lack training to adequately perform these functions. The 1985 

Invitational Conference on Issues and Strategies in Geriatric Education noted 

deficiencies in nurse supervising and teaching skiIs, and indicated nurse education 

programs do not routinely offer training in these areas. Compounding these 

problems are the numerous responsibilties nurses have in other areas (e. 

administrative paperwork). 

In some homes, the ratio of nurses to nurse aides may be inadequate, just as the 

ratio of nurse aides to residents may be inadequate. In order to meet State or 
Federal facilty staffing requirements and to quickly fiI vacancy positions which may 

result from high turnover rates, many nursing home administrators have chosen to 

use temporary servces. Some respondents believe use of such servces (nurse and 

nurse aide pools) may be on the rise. Although temporary employees can fiI critical 

staff shortages, several respondents expressed concern that temporary employees may 

not have been adequately screened or trained to care for nursing home residents. 

RECOMMENDATIONS 

Because this inspection indicates abuse may be a problem for nursing home 

residents, we recommend the following: 

The Health Care Financing Administration (HCF A) should: 

Require, as part of its nurse aide training regulations, ongoing 

training concerning the aging process and mechanisms to cope with 

and avoid confrontational situations. Further, nursing homes should 

be required to document staff training and understanding of abuse 

and reporting responsibilities and procedures for abuse incidents. 

Require, as part of the admission requirements for a new resident 

nursing homes to inform residents about differences between living 

in a nursing home environment vs. living at home, possible problems 

they rimy encounter, and ways to deal with such problems. 

Require, as part of its conditions of participation for nursing homes 

supervsory and training staff to acquire skiIs necessary to effectively 

train and supervise paraprofessional and nonprofessional staff. 

The HCF A should further support research concerning long term care 

policies which promote staff stabilty and provide for adequate staff-toresident ratios necessary to control stress and abuse. 

The Administration on Aging (AoA) should collect and disseminate 

information about nursing home practices which avoid stress and abuse 

and promote staff stabilty and adequate supervsion. 
DEPARTMENTAL COMMENTS


Comments were received from the Assistant Secretary for Planning and Evaluation 

the Office of Human Development Services, the Administration on Aging, and the Health Care Financing Administration. (See appendix D for the full texts. 

Assistat Sereta for Planning and Evaluation (ASPE) 

The ASPE agreed with the findings and recommendations of the report. More 

specifically, it "supports the OIG's recommendations for improved training of nurses 

aides and orderlies about how to cope with stressful situations and resident behaviors 

without resorting to abuse. 

Ofce of Human Deelopment Services (OHDS) 

The OHDS concurred with the report. 

Administrtion on Aging (AoA)


The AoA agreed with the findings and recommendations of the report. 

Healt Cae Financing Administrtion (HCFA) 

While the HCF A generally agreed with the report, it did have concerns with the 

primary data gathering technique utilzed, that is, an opinion survey rather than a 

scientifically controlled review, which resulted in opinion data "presented as fact." The HCF A also felt it would be advisable to include more information about the 

intervews and information gathering processes used in the study. 

Additinal infonnatin has been provided in the Scope and Methodology sectin of the 

report. Although evaluatin stuies do not produce absolutely certain infonnatin, they

can provide relatively objective data. As the report indicated, there was little relevant 

statitical or applicable published research data concerning abuse in a nursing home. 

We started with an assumptin that inividuals who routinely receive complaints of 

abuse, survey for inicators of abuse, investigate abuse, or resolve abuse incidents are knowledgeable sources. The survey method was designed to provide descriptive 

infonnatin of extig processes using statements of opinion from a representative populatin. Findings and recommendatins related to the survey (to identify whether abuse was a problem, to what extent, etc.) were a result of both content and qualitative 
analyses of the survey responses, available State statistis and legilatin/regulatin, and 

available research. We recognize the information provided by the respondents is 

signifcant only in the way it is regarded by the researcher or the readers. There is no 

absolute interpretatin of the informatin provided. 

GeneraIIy, the HCF A agreed with the recommendations of the report. The HCF A 

believes their implementation of the applicable statutory requirements of the 

Omnibus Reconcilation Act (OBRA) of 1989 and the Social Security Act will fulfil 

the recommendations of this report. In meeting a portion of the legislative 

requirements, the HCF A has revised the conditions of participation for nursing 

homes (effective October 1, 199). The HCFA believes the revised requirements will 

contain many of the safeguards recommended by the OIG. 

The HCF A inicates many of the recommendations will be met by the new regulatins. 

We agree that draft regulations issued thus far represent a substantial improvement over 

regulatins now in effect. However, some of these regulatins are still in the public 

review and comment stage and may change. Even more importantly, the regulations 

defer to State law on the critical issues of complaint reportng, investigating, and followup. Hence, their impact will depend greatly on how aggessively the States move on these problems. Similarly, nursing homes wil have to comply with the State law. We 

will, therefore, defer any assessment of whether our recommendations have been 

implemented until the new regulatory requirements are in place and States and nursing 

homes have made at least initil efforts to implement them. 
APPENDICES


APPENDIX A


NATIONAL ORGANIZATION RESPONDENTS 

American Association of Homes for the Aging 

1129 20th Street, NW 

Washington, D. C. 20036 

American Association of Retired Persons - Central Office 

Criminal Justice Servces 

1909 K Street, NW 

Washington, D. C. 20049 

American Health Care Association 

1201 L Street, NW 

Washington, D. C. 2005 

American Medical Directors Association 

12100 Blue Paper Way 

Columbia, Maryland 21044 

National Aging Resource Center on Elder Abuse 

Research and Demonstration Department 

810 First Street, NE 

Washington, D. C. 2002-4205 

National Association of Attorneys General 

444 N. Capitol Street, Suite 403 

Washington, D. C. 20001 

National Association of Chiefs of Police 

1100 NE 12S Street 

Miami, Florida 33161 

National Association of State Units on Aging 

2033 K Street, NW, Suite 304 

Washington, DC 200 

National Citizen s Coalition for Nursing Home Reform 

1424 16th Street, NW 

Washington, D. C. 20036 
National Sheriffs Association


1450 Duke Street 

Alexandria, Virginia 22150 

Police Executive Research Forum 

2300 M Street, NW, Suite 910 

Washington, D. C. 20037 

Police Foundation 

1001 22nd Street, NW Suite 200 

Washington, D. C. 20037 

Rehabilitation Care Consultants, Inc. 

6401 Odara Road 

Madison, Wisconsin 53719 
APPENDIX B


Tables I-VII Present Respondent Perceptions on Abuse Categories as Problems 

Extent of the Problem, and Whether the Problem is Perceived as Worsening. 

Table I 

Table II


Table III


Table IV


Table V


Table VI


Table VII


Physical Abuse 

Misuse of Restraints 

VerballEmotional Abuse 

Physical Neglect 

Medical Neglect


VerballEmotional Neglect


Personal Property Abuse 

... ..

.... .. ......... .. ....... ...................

PHYSICAL ABUSE 

RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 

SEVERITY OF THE ABUSE 

FOR RESIDENTS 

100% 

90% 

80% 74% 

"- I­ 70% 

I- W 60% 57% 

50% 

a: (L 50% 

42% 

(L W 40% 38%38% 

30% 

30% 33% 

25% 

31% 

22% 

20% 17% 

11% 

10% 

:: 0% 

STATE ST A TE ST ATE 

COMPLAINT MFCU SURVEY AND 

COORDINA TOR CERTIFICA TION 

ABUSE TREND: 

IS IT GETTING WORSE. 

BETTER OR STAYING THE 

SAME FOR RESIDENTS 

100% 

"-I­ 59% 60% 

I- W 

49% 48% 

a: CL 

CLW 40% 39% 

43% 

26% 27% 

20% 

10% 

TABLE I


100% 

90% MAJOR 

PROBLEM 

80% 

70% 

MODERA TE 

60% PROBLEM 

50% 

40% MINOR 

30% PROBLEM 

PROBLEM 

MAJOR AND 

MODER A TE 

COMBINED 

100% 

90% 

80% 

WORSENING 

70% 

60% I::::::::j 

50% IMPROVING 

40% 

30% 

STAYING 

20% THE SAME 

10% 
_... _._

TABLE " 

MISUSE OF RESTRAINTS 

RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 

SEVERITY OF THE ABUSE 

FOR RESIDENTS 

100% 100% 

90% 90% MAJOR 

80% 80% 

PROBLEM 

LL (J 70% 70% 

I- 60% 57% 56% 60% MODERA TE 

PROBLEM 

ff(J 

50% 

40% 36% 

46% 44% 

38% 

44% 50% 

40% 

32% MINOR 

30% 27% 26% :: 30% PROBLEM 

20% 18% 19% : 19% 20% 

10% 10% PROBLEM 

MAJOR AND 

MODER A TE 

COMBINED 

ABUSE TREND: 

IS IT GETTING WORSE. 

BETTER OR STAYING THE 

SAME FOR RESIDENTS 

100% 00% 

90% 90% 

80% 80% 

WORSENING 

LL I­ 70% 70% 

I- W 

a: 0­ w(/

O-W 

60% 

50% 

40% 

54% 

34% 

48% 

53% 

39% 

47% 48% 

60% 

50% 

40% 

I::::q 

IMPROVING 

30% 26%26% 27% 

30% 

30% 

20% 20% 

14% 

22% 

20% 

STAYING 

THE SAME 

10% 

ST ATE ST A TE STATE STATE STATE 

COMPLAINT MFCU SURVEY AND OMBUDSMAN NURSING HaM 

COORDINA TOR CERTIFICA TION INDUSTRY 
........ ... ...

T ABLE III 

VERBAL/EMOTIONAL ABUSE 

RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 

SEVERITY OF THE ABUSE 

FOR RESIDENTS


100%	 100% 

90% 90% MAJOR 

PROBLEM 

80% 80% 

70%	 70% LL I- 54 % -..-..-..-.-. MODER A TE 

I- W 60%	 56% 60% PROBLEM 

a:Q	 50% 45% 43% 43% 50% 

39% 1.../ 

40% 32% 31% 36% 33% 40% MINOR 

30% 30% PROBLEM 

20% 21% 21%	 18% 20% 14% 

10%	 10% PROBLEM . 0%


ST A TE ST A TE 

MFCU SURVEY AND MAJOR AND 

CERTIFICA TION MODER A TE 

COMBINED 

ABUSE TREND:


IS IT GETTING WORSE. 

BETTER OR STAYING THE


SAME FOR RESIDENTS


100%	 00% 

90%	 90% 

80% 71% 

80% 

WORSENING 

70% 70% LL I-	 62% 

I- W	 60% 54% 53% 60% I/)(j 

50% 50% 47% 50% IMPROVING 

a:Q 44%


w(f 40% 37% 40%


30%	 30% 

24% ST A YING 

20% 19% 19% 20% THE SAME 

10%	 10% 

5T A TE ST A TE STATE STATE STATE 

COMPLAINT MFCU SURVEY AND OMBUDSMAN NURSING HOME 

COORDINA TOR CERTIFICA TION INDUSTRY 
,,

_,__..\ ...

TABLE IV 

PHYSICAL NEGLECT 

RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 

SEVERITY OF THE ABUSE 

FOR RESIDENTS 

100% 100% 

90% 90% MAJOR 

80% 80% 

PROBLEM 

u. f­ 70% 65% 70% 

60% 57% 53% 60% MODERA TE 

PROBLEM 

a: CL 50% 47% 46% 50% 

CL W 40% 37% 40% 

40% 1(,.,)' 

MINOR 

30% 27% 30% PROBLEM 

20% 19% 13% 

, 15% 20% 

10% 10% PROBLEM 

STATE STATE STATE ST A TE 

MFCU SURVEY AND 

CERTIFICA TION 

OMBUDSMAN NURSING HOME 

INDUSTRY 

MAJOR AND 

MODER A TE 

COMBINED 

ABUSE TREND: 

IS IT GETTING WORSE. 

BETTER OR STAYING THE 

SAME FOR RESIDENTS 

100% 100% 

90% 90% 

80% 

WORSENING 

LL f­ 70% 

54% 61% 56% 60% 1.())1 

a: CL w(j

CLW 34% 32% 

40% 

47% 

33% 

43%43% 50% 

40% 

IMPROVING 

30% 

20% 20% 

STAYING 

THE SAME 

10% 10% 
.. _.._................... ...

T ABLE V 

MEDICAL NEGLECT 

RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 

SEVERITY OF THE ABUSE 

FOR RESIDENTS 

100% 100% 

90% 90% MAJOR 

PROBLEM 

80% 80% 

e/ 70% 70% 

ft;z 

wCf 

CL 

60% 

50% 

40% 

30% 

57% 

27% 

41% 

30% 

26% 

56% 

25% 

44% 

32% 

21% 

54% 

27% . 

60% 

50% 

40% 

30% 

MODERA TE 

PROBLEM 

I?:o\o:/:I 

MINOR 

PROBLEM 

20% 13% 20% 

10% . 6% 10% PROBLEM 

ST A TE ST A TE STATE ST ATE 

COMPLAINT MFCU OMBUDSMAN NURSING HOME MAJOR AND 

COORDINA TOR INDUSTRY MODERA TE 

COMBINED 

ABUSE TREND: 

IS IT GETTING WORSE. 

BETTER OR STAYING THE 

SAME FOR RESIDENTS 

100% 100% 

90% 90% 

80% 80% 

WORSENING 

u. f­ 61% 

70% 

f- W 54% 53% 56% 60% 

a: CL we/

CL W 

50% 

35% 32% 

44% 

33% 

50% 

40% 

IMPROVING 

30% 

20% 

28% 27% 

20% O 22% :. 30% 

20% 

STAYING 

THE SAME 12% 12% 

10% 10% 

STATE STATE ST A TE STATE STATE 

COMPLAINT MFCU SURVEY AND OMBUDSMAN NURSING HOME 

COORDINA TOR CERTIFICA TION INDUSTRY 
.,,. / 

__,,,,,,,:

T ABLE VI 

VERBAL/EMOTIONAL NEGLECT 

RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 

SEVERITY OF THE ABUSE 

FOR RESIDENTS 

100% 100% 

90% 90% MAJOR 

PROBLEM 

80% 

ft5z 

UJ (/

Q. 

70% 

60% 

50% 

40% 

44% " c. 

38% 

44%44% 

39% 42% 

38% 38% 

70% 

60% 

50% 

40% 

MaDERA TE 

PROBLEM 

I,,,,,,,, 

MINOR 

23% 

27% 19% 30% PROBLEM 

20% 

10% 10% PROBLEM 

MAJOR AND 

MaDERA TE 

COMBINED 

ABUSE TREND: 

IS IT GETTING WORSE. 

BETTER OR STAYING THE 

SAME FOR RESIDENTS 

100% 100% 

90% 90% 

80% 80% 

WORSENING 

L1 f­ 70% 

64% 63% 62% 

70% 

f- UJ 60% 60% 

50% 50% 

a: Q.

UJ (/

Q. UJ 

50% 44% 

38% 41% 

50% 

40% 

IMPROVING 

32% 

30% 

20% 20% 

STAYING 

THE SAME 

10% 10% 

ST A TE ST A TE STATE ST ATE STATE 

COMPLAINT MFCU SURVEY AND OMBUDSMAN NURSING HOME COORDINA TOR CERTIFICA TION INDUSTRY 
_. 

. .

TABLE VII 

PERSONAL PROPERTY ABUSE 

RESPONDENT PERCEPTIONS OF SEVERITY AND TREND 

SEVERITY OF THE ABUSE 

FOR RESIDENTS 

100% 100% 

LL if 70% 

o!z 

f- 60% 

ijz 50% 

ffif 

40% 

90% 

80% 

30% 

20% 

39% 

33% ,:,' 32% 

56% 

44% 

38% 

- -.- h-n_n_..-u,,-.. - n_ 

53% 

26% 21% 

41% 

34% "~c 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

MAJOR 

PROBLEM 

MODERA TE 

PROBLEM 

L'o;:):,J 

MINOR 

PROBLEM 

10% 10% PROBLEM 

ST A TE 

OMBUDSMAN 

ST A TE 

NURSING HOME 

INDUSTRY 

MAJOR AND 

MODER A TE 

COMBINED 

ABUSE TREND: 

IS IT GETTING WORSE. 

BETTER OR STAYING THE 

SAME FOR RESIDENTS 

100% 00% 

LL ff- W 

a: (L 

(LW 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

29% 

68% 

21% 

79% 

57% 

21% 21% 

25% 

69% 

56% 

22%22% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

WORSENING 

I"""",:"""", 

IMPROVING 

ST A YING 

THE SAME 

10% 10% 

ST A TE 

COMPLAINT 

COORDINA TOR 

STATE 

MFCU 

STATE 

SURVEY AND 

CERTIFICA TlON 

STATE 

OMBUDSMAN 

STATE 

NURSING HOME 

INDUSTRY 

APPENDIX C 

DEPARTMENTAL COMMENTS 

Comments on the draft reports were received from four Department of Health and 

Human Servces entities - the Assistant Secretary for Planning and Evaluation, the 

Health Care Financing Administration, the Office of Human Development Servces 

and the Administration on Aging. The full texts of their comments are attached. 

DEPARTMENT OF HEALTH &. HUMAN SERVICES	 OHice of the Secretary 

""'''h1	 Washington , D, C, 20 

MEMORADUM DEC 2 9 1989 

TO:	 Richard Kusserow 

Inspector General 

FROM:	 Arnold R. Tompkins 

Acting Ass 9tant Secretacy for Planning and Evaluation 

SUBJECT:	 OIG Draft Reports: (1) "Resident Abuse in Nursing 

Homes: Respondent Perceptions of Issues" and (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 in nursing homes and 

recommending strategies for dealing with it. OASPE supports the 

OIG I S recommendations for improved training of nurses aides and 

orderlies about how to cope with stressful situations and 

resident b haviors without' resorting to abuse , improved abuse 

complaint investigation and resolution as part of state 

enforcement of Federal nursing home regulations , and improved 

systems for abuse reporting. 

In my view , these two reports merit the widest possible


dissemination among Federal and state agencies concerned with


nursing home regulation as well as among the nursing home


industry 'and consumer groups. 

_._. 

Health Care 

DEPARTME T OF HEALTH So HUMAN SERVICES Financing Administration 

-r--­

Memorandum 

Date jJ. Los B, Hays 44­

From Acir 

OIG Drft Rert: Reident Ab in Nuir Han: 

Subject (1) Rerrt Peion of Iss---06-88-00360, (2) Relvir Ibysica Ab C:lai---06-88-000361 

'le Inr Office of the 

We ar to ya re for ca on th tw sujec rert. Fir, we digr with you st methodolog, paicuarly with re to the Rerrt Peion of Iss st. Hcer, genly agr with th retions, am:r ha aldy be done 

stes we don uner the to a lis the re maes. 'l cu cation of paicipation, whdl will be in effec tmtil Oc 1, 1990. On tht date, reis re, whch cotain may 

of th safeg re ..,. by OIG in th re wil go 

effec. We do DX beieve it wcd be aprqriate to ma aationa 

es at th t..


We beieve it wcd be adisle to inlud nore ino:rtion abt 

the iniew ar inonntion gatherir pro us in th st. 

app the data gatherir pro wa an opinon suey, rather th 

scientificaly cotrlled reieW. Yet the data we prete as fact. 'I te to proce th rets fou; i. e. CI am .oter officials inesigate ab th it is a prclem, whe thos reretir nuiI ha quion th. seioo of th f 

QJ ca on th spific retions ar attched. Plea 

advis us whth you ag with ou poition at yc ealies 

coenen.


Attclt

Page 2


HCA O:ts 

We agree with ths reccllllendation an have be aci vel y p.rsing ths end. As part of th nue aide traing an cctecy evaluation program regation rrtianed in 1a, th Seretary is reqired to establish regation for th qualification of intructrs of nuse aide traing and cctency evaluation progcr. Whe we caot predict th preise 

content of th fin rues, thre wil be mi qualification for the intructors. Alo , 42 er 483. 30 inicates tht facilities "rrt have 

sufficient nursing stf to provide nursing an relate service to attain or maintain th high practicale physical, rrtal, an pschocial well-being of each resident as determed by resident assessrt plan an individual care plan. This wwd include th survisory Inrsing staff having th necsar skils to supervise direc care staf in a maer

consistent with resident rights, llluding th right to be free fran ab.e . 

Recation No.


H:A shod conduct fur research cocerng long term care P=licies which prcrte stff stility an provide for adeqate stf-patient ratios necsary to cotrol stress an ate. 

H:AO:ts 

We beieve tht we hae alreay develop . an appropriate rr for 

enring tht facilities have adeqate an appropriate staff. metioned in wrrese to Recation 1c, H:A wil reqre tht 

facilities have suficient staff to provide for th nees of residents, hCer, it is clea tht increing stf-resident ratios alone wil not cotrol ate. Th wtcoriente reremt gives facilities main flexibility in determg th ways th wil proide for staff staility an ene tht th nees an rights of reidents are 

met. We alo note tht any furtr research in ths area wod reqire additional fuing. 
OIG recs tht lCA, as part of its coition of participation for 

hospi tals and nursing ha, shcud: 

Reccration No.


Reqire al nursing ba staff an hospita rrical personel to report al suEr incidents of abe to th nursing ba adrator loc law enorcat an to th cetral agency assignEr resibility 

for resolution of ahe calaits.


lOA O:ts


We do not agree entirely with ths recation. we wil rere,


effecive CXober 1, 1990, at 42 er 483. 13 (for mrsing ha), tht al aleged ahe be report to th mrsing ba adtrator or othr official in accrdan with state law. lDA hospita coition

participation an th Joint Casion on Acreditation of Hethre 

Organzation staars do not reqire reprting .of ahe. Hcer, th

hospital coition of participation do rere tht hoita follCM 

state law. we ar not aware of a signficat abe problan in hoitals 

an do not l:ieve we ne to revise cur coition of paicipation. 

do not l:ieve tht th OIG ha dartrate a signficat problan with re to hoita. 

Recation No.


Reqire mrsing ha to reprt al abe inidents to loc law
 enorcat, th cetral agcy assigner resibili ty for resolution of ahe calaints an to th state SUrvey an Certification Ag. 

H:A Ccts 

We do not agree fuy with ths tecmenatian. Agai, effecive O:ber 1, 1990, we wil reqire tht al aleger ince of ahe reprt to th m.sing ba adrator or cutside official in 

accrdance with state law. we beieve ths is suficient an tht mior ahe incidents ca be effecively haer by th aCstrator wi tht 

th nee for invol vart of law enorcat personel. 

Recdation No.


Reqire nursing ha to matain report of su incidents of abe 

an the action taen by th nursing ba. 

H:A Cats 

We agree and l:ieve tht th new regation, which reqire tht nuing ba condct investigation of aleger are, matain evidence of 

investigations, an tae correcive action whe ahe is verifier, wil satisfy ths reation. 
Page 2


Recation No. 

ire adstrators to coct anysis of al incident reprt determe imlication and appropriate acion. 

H:A O:ts


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


Recardation No.


ire nursing ha to spify, as pa of th nursing ha residents plan of care, .a plan to prevent abe of a reident who is eithr metaly or physicay unle to prote hiherself. 

HCA O:ts 

We agree an believe tht th new regation cor ths issue. The regation at 42 CE 483. 20 provide for a c:rehive assessrt an developrt of a plan of care for every resident. The plan assessrt an plan of care shwd include any spial resident nees, inuding spific 

steps for prevention of ahe, if nesar. 

Recdation No.


ire nusing ha to proide oogoin rrtoring an caeling emloyee su. of abing residents. 

IUA O:ts 

We disagree with th eculIendaticn. Coeling o:d be ineqate, an

we do not l:ieve tht person su of abe shadbe cotine to work with residents whe being c:eled. Their bevior 

Itt be 

are not net. 

appropriate or th nu be raed fran th job if extion

oter Recations 

HCA agree with th recation for state an loc resibilities, resolution an follCMp tht reires each state to natain retrievable data for IDA. 

In addition, lCA also agr with th joint recation tht lCA and 

th Adstration on Aging develop ccn defintion an categories of abe for al state an Feeral reprting p.rpes. We wil work toard ths end. 
:::

Office of 

DEPARTMENT OF HEALTH &. HUMAN SERVICES	 Human Development ervices 

Assistant Secretary 

Washington DC 20201 

DEC 22 1989 

TO:	 Richard P. Kusserow 

Inspector General 

FROM: Assistant Secretary 

for Human Development Services 

SUBJECT:	 Draft Reports on (1) "Resident Abuse in Nursing Homes: 

Respondent Perceptions of Issues, " OAI-06-88-00360 and 

(2) "Resident Abuse in Nursing Homes: Resolving


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


Thank you for the opportunity to review the draft reports on

Resident Abuse in Nursing Homes. We ,concur with the draft 

reports. 

If you have any questions, please contact Deborah Bass at


245-3176. 

Mary Sheila Ga


/kL

DEPARTMENT OF HEALTH &. HUMAN SERVICES	 Off of the Secretary 

Administration on Aging	 Washington , D, C. 20201 

JAN - 9 1990 

TO:	 Richard P. Kusserow 

Inspector General


FRO	 Acting Commissioner on Aging 

SUBJECT:	 Comments on the OIG Draft Reports on Resident 

Abuse in Nursing Homes 

The Administration on Aging (AOA) appreciates the 

opportuni ty to comment on the OIG draft reports wResident 

Abuse in Nursing Homes: Respondent Perceptions of Issues 


and w Resident Abuse in Nursing Homes: Resolving physical Abuse Complaints. We are pleased that the current draft 

reports incorporate changes which respond to most of the 

concerns that AoA expressed about the earlier draft


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


diligence in making the necessary changes. 

While most of our comments have been addressed, we continue 

to have serious concerns about one major item in the report 

on Resolving Physical Abuse Complaints. The Executive 

Summary (p. iii) under Recommendations relating to Federal

Responsibi ities proposes, among other things, that the 

Administra tion on Aging should expand and strengthen its 

efforts to issue periodic public reports concerning abuse trends. This topic. is discussed further on page 17 of the 

report which notes that, while the AoA Ombudsman Report is a 

major indicator of nursing home abuse, it cannot be used to 

obtain reliable national counts of abuse (particularly for 

specific problem areas. The report goes on to state that, 

for several reasons which are cited (p. 18), there are no 

adequate national nursing home abuse statistics to provide 

an incidence rate or trend for nursing home abuse. 

We concur with the observation that there are no data which


can be used to provide an incidence rate or trend regarding


nursing home abuse. The impediments to the collection of


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


AoA to overcome. Ther fore, it is not possible for AoA to 

respond to the report' s recommendation to expand and


strengthen its efforts to issue periodic public reports


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


conclusions regarding the significant nature of impediments


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

!

p

- 2­


the recommendation concerning AoA which appears on p. iii
 the Executi ve Summary delete any reference to issuance of


reports on abuse trends and be revised to read:


The Administration on Aging (AOA) should expand and


strengthen its efforts to 1) issue best practices for


preventing and dealing wi th resident abuse, 2) promote
 public awareness and education concerning abuse occuring


in nursing homes and 3) promote use of volunteer


Ombudsman in nur sing homes.


Again, we appreciate the opportuni ty to review and comment 

on the draft reports prepared by OIG. 
APPENDIX D 

PUBLIC COMMENTS 

Comments were received from several organizations with interests pertaining to the 

elderly, nursing homes, or law enforcement: 

American Association of Homes for the Aging 

American Health Care Association 

National Aging Resource Center on Elder Abuse 

National Association of Chiefs of Police 

National Association of Medicaid Fraud Control Units 

National Citizen s Coalition for Nursing Home Reform 

Police Executive Research Forum 

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. AIl comments were reviewed and analyzed. Findings 

and recommendations in both final 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. 1 am further disturbed by your failure to adequately define the term, 

abuse " which has resulted in confused and unreliable findings." (Nursing Home


Advocate)


We must assist familes who have loved ones in a facilty to becme more aware of the 

aging procs and the circumstance surrounding the institution living. Consideration 

should also be given whereby training modules are made available to and participation in 

them encouraged for relatives and friends of the institutionalized aged and infirm. 

(State Complaint Cordinator) 

We feel strongly that your report should acknowledge the costs to the Medicaid and 

Medicare programs of such (supervisory training for direct care supervsors) training, as 

well as the time diverted from patient care activities to fulfll such requirements -­

particularly at a time when there is a national shortge of skiled nursing personnel." 

(Nursing Home Advocte) 

feels strongly, and the final report of the National Commission on Nursing recgnize, 

that the Medicaid program -- through inadequate reimbursment -- actually limits 

nursing home providers' abilty to recuit and retain adequate members of highly skilled 

nursing staff. We believe that HCFA, in approving State Medicaid reimbursement plans, 

must ensure that reimbursement rates allow nursing homes to compete with hospitals 

and other health care providers for scarce nursing staff." (Nursing Home Advocte) 
I would like to see a study on the emotional makeup of the abusing aides to include mental health exams and espeially depression scales since peple with mild mental ilnesses get much worse under stress and may be impulsive or neglectful. To prevent medical neglect I would like to see physician training in geriatrics and medical directorship be much more widely required, and a strong medical director system in nursing homes... (Physician) 

The resistance to recmmendations of this nature (involving attitudes and understanding behaviors) revolve around funding. At the risk of oversimplification, some of the problems might better be addressed and resolved if there were not the present and near impossible crazy quilt of 50 different State reimbursements for Medicaid. And there might be far less medical neglect if Medicare did not discriminate against payments for physician visits for patients in nursing homes." (Nursing Home Administrator) 

Require Medical Schools to offer courses in geriatrics, and require rotation of interns in . nursing homes; move toward nationalization of Medicaid payments.

Administrator) " (Nursing Home 
APPENDIX E


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