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RESIDENT ABUSE IN NURSING HOMES 

RESOLVING PHYSICAL ABUSE COMPLAINTS 

Richard P. Kusserow 

INSPECTOR GENERAL 

OEI-0688-001 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 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 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 

for the findings and recommendations of this report. 

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 tyes of abuse statistics collected under existing State and Federal 

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 

APPENDICES A. B. State Eldert or Nursing 

National Organization Respondents 

Home Laws and Regulations C. D. E. F. 

Departmental Comments

Public Comments

Bibliography 

Degree of Nursing Home Abuse Reporting 
.. .... ...

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


NUMBER (IN MILUONS) 

PECEN OF POPULATI 

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

10 -.. 

1970 198 199 20 2010 2020 YEAR SO Cl PO T1 RES NO. 

us CE IUU 

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

Z 0


198 1990 20 2010 2020 

YEAR IO AQ AI 188-8 PMAN 8Y U oS. 8!TI 8I ADT1 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.)J. 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 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 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, supervse, 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 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, 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 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 

The priary respomibilit for designing, operating, and coordinating services for the 

elderly lies with the States. 
 Severed State agencies may be responsible for resolving 

nursing home problems including: . '1 ' 

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). 

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

and collect statistis, we decided to survey knowledgeable individuals involved directly or 

inirectly 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 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


Infliction of mental/emotional suffering.


3. 

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. 

6. Verbal/Emotional NeQlect 

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 

7. personaLPropert 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 Washington Indiana Nevada Wisconsin 

Illnois New Hampshire Wyoming * Kansas New Jersey 

States with no Medicaid Fraud Control Unit 

* Sta tea Visited Onslte


SURVEY RESPONDENTS BY ROLE


ot All Type of Respondent Number Respondent 

State 

Complaint 16% 

Coordina tor


Survey and Certification


Surveyors 

MFCUs Or Counterpart 18% 

Professional Medical


Licensure Boards


Ombudsman 16%


Residenl Advocacy


Organlza tlons


Nursing Home 13% Industry 

National Organizations 

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)). 

. Penaes for noreportng va 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. 
Mo Stes hae id an indivdual to recive coPiaint resid ab. ofen by mea ne.. Yet. rePOna doe no 

ocr. 

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-free 24-hour manned line. When not manned 

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 the nowled.&

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 

that the residents most vulnerable to abuse are physically or mentally 

impaired and, consequently, have diffculty reporting. Even those 

aware something is wrong may be unable to articulate their concerns 

or to recognize the perpetrator of the alleged abuse because of those 

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 ofen go unrepoed by nursing home st. 

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, 

lack of clear or suffcient facts, and 

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. 

. A maor of resnt say atending nursing home physician rarely or 

neer report ab; 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 

are too busy to report or do not recognize the. abuse. According to respondents 

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 questions about the effectiveness of current 

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 Federal agencies having roles in the reslut of abus 

coplaint. 

Assessing and resolving abuse is rarely simple. Many States have several agencies 

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 

investigative role. Additionally, respondents indicate HCFA and the AoA do not 

usually participate in investigations concerning individual abuse complaints and 

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 Attorney General's Health Care Fraud Unit. In almost


all ca 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.

While mo Stes hae regula or laws governing the init of an ines, ma respont indice their Ste doe no ha eslis 

time limit fo coplng ines or st wi invesgae baground 

to pe all ines regardles of the ty of alleged ab. 

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 

complaint is th nursing home administator or someone to wh 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 

administrator. The administrator, or someone to whom s/he in turn has 

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. 

Ma respoden repo lo law enforcement autories are rarely involved 

in th invesgat 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. 

In mo Stes, Ste Ombuen serve as a refrral source bu do not hae aut to tae displina ac. 

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. 

. Mos respo are unfilia wi 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 

substantiated complaints under criminal laws, and 

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 of subsated abuse incident is hindered by the difcult of 

provinQ the abuse an obtninQ the evidence reauired for proson. When 

cormed. mo ins 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 substantiated 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. 
Ma Stes de ab an cole st 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 

limit it us fo ansis of natnal incidence trends or the prevalenc of 

abus. The level of reportng detl is too broad for adequately monitoring nursing hoe resnt 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 

idented problems wi it use an 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. 

to' Because resident 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 to coucng Fedal or Ste 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 

responsibilties of the involved local, State, and Federal entities. As a result, even in 

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. 

Assistat Sere 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. 

Administrtion on Aging (AoA

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. 

Hea Ca Financing Administrtion (HCFA)


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 followup. 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 

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 

Rehabiltation Care Consultants, Inc.


6401 Odara Road 

Madison, Wisconsin 53719 
APPENDIX B


STATE ELDERLY OR NURSING HOME LAWS AND REGULATIONS 

The following is a compilation of laws 
 nd regulations provided by respondents and


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. 

Bil of Rights for Residents of Long-term Care Facilities of 1981, O. 

Disabled Adults Protecion Act of 1981, O. A, 30­

Domestic Violence Act of 1981, O. A, 19-13- 1 et seq. 

, 31­

, 3­

80. 

100. 

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-Term Care Ombudsmen, Chapter 50- 10. , SL 1983, Chapter 524; SL 1985, Chapter 524; SL


1987, Chapter 576. 

Ohio 

Patient Rights, Health-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,
 1986. 

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 

Report of Abuse, Neglec and Exloitation of Elderly and Disabled Adults, Title 18, Chapter 22 

amended 1983, 1985, 1986, 1987.
 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


PERCENT OF 

RESPONDENTS Degree of 

Reporting 

100% 100% 

90% 90% 

80% 80% AL WAYS 

70% 66%, 70% 

60% 60% USUALL Y 

50% 4 7% 50% 

40% 37% 400/ 36% co;;;; 38% 37% 40% 1//:://1 

30%	 30% SOMETI 

20%	 20% 13% 

10%	 10% 

RAREL Y


ALL EMERGENCY NURSING HOME ATTENDING ROOM 

REPORTERS STAFF PHYSICIANS 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. 

As an example, for nursing home staff: 	 13 percent of 

respondents believe staff always report abuse, 36% 

believe staff usually report abuse, and so on.
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 General 

FROM:	 Arnold R. Qns Acting Ass 'ta for Planning and Evaluation 

SUBJECT: OIG Draft Reports: (1) "Re ident 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 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- ---.-----­


"10 Memorandum 

Date 

If 

From 

OIG Drft Rert: Reident Ab in Nuin Ha: 

Subject (1) Re Peon of Iss-a-Q6-SS-00360, (2) :Rlvin lbysica Ab Calai-a-Q6-SS-000361 

'!e Inr 

Office of th 

We ar rerr to yo re for cc on th tw sujec rert. Fir, we digr with yo st methodolog, pacuarly with re to the Rerr Peion of Iss st. Hcer, genly agr with th re.,.,.,.rtions, ar mu ha aldy be done to aa:lis the re ches. 'l stes we do urer the Oc cu cotion of pacipation, whch will be in effec until

1, -1990. On tht date reis re, whch cotain may of th safeg re",, by OIG in th re wil go

effec. We do oo beieve it \od be awrcriate to DB adtiona d1es at th ti. 

We beieve it wod be adisle to inud mre ino:ction abt the iniew ar ino:rtion gatherin p us in th st. app the data gatherin prc wa an opinon suey, rather th scientificaly colled reiew. Yet the data we prete as fact. '! te to prc th rets fou; i. e., an ar officials wh inesgate ab th it is a prclem, whe thos reretin nuin ba quon th seiou of th fins. 

CX cc on th spific :rtion ar attd1. advis us whth yoo agr with an poition at yo ealies Plea 

COenen. 

Attd1 
III 

Iii 

: I


O:ts of th Heth Care Financing Mnstration (lCA) 

on eIG Draft Audit R rt on Resident Abe in Nursing Ha: Resent Per ion of Issues--(Qa-06-88-00360) 

Reccmation No. la 

HCA shod reqire as part of its nurse aide traing regations, ongoing traig cocerng th aging procs an rrsr to cope with and avoid corontational situation. E\rtr, th nursing ha shod 

be reqired to dcxt staff traig an unerstaing of ale and reporting resibilities an prores for ale incidents. 

HCA O:ts 

We agree with ths recation an have be actively workig to imlemt it. Seion 1819 (f) (2) an 1919 (f) (2) of th Soial Serity Act (the Ac) reqire th Seta to esish reation for state nurse aide traing an CC evaluation procm. Seion 

6901(b) (2) of th 0m aJge Recciliation .A of 1989 (CE 89) reqires tht th Sereta issue proped regation on nue aide traing an catecy evaluation procm with 90 days of enctt. Secion 6901 (b) (3) of OB 89 m:ifier th OJria.un for th traig include "baic nursing ski, person cae ski, rection of rrta heath an social service ne, ca of cotively imred reidents, baic restorative service, an residents' rights. .. we l:ev tht imlemtation of the sttutory alialun reqrerts wil fufil eIG' recation. H:A is o.tly workig to issue th proed rues. Althgh we caot be cert of th preise cotet of th fin 

rues, we ca assue ycu tht th wil provide for procm tht encorage th be :fsible ca for residents. 

Recation No. 1b 

lCA shod reqire, as pa of th a:sion rerats for a ne resident, nuing ha to provide gudance to reidents corng th difference in living in a nuing ha enviramt, J:sible probler they may encater an ways to dea with such probler. 

H:A O:ts 

We believe th recation is addresed in Feeral reation at 42 

er 483. 10 which are to be effecive O=ber 1, 1990. Thi proision reqires tht residents be notified of thir rights an service. 

Recdation No. Ic 

HCA shod reqire, as pa of its coition of participation for nursing ha, stff resible for survising or traing dire care staff to acqire skil necsar to effecively train an survise 

paraprofessional and nonprofessioo stff. 
Page 2


H:A o:ts 

We agree with th recllenation an have be acively p.rsing ths en. As part of th nue aide traing an CGtecy evaluation progran regation rrtioo in la , th Seretary is reqired to esablish regation for th qualfication of intructrs of nue aide traing and c:tecy evaluation progCl. Whe we cat predict th preise cotent of th fin rues, thre wil be mi qualification for the 

intructrs. Alo, 42 em 483. 30 indicates tht facilities "ITt have sufficient nuing stf to provide nursing an relate service to attain 

or maintain th high practicale physica, meta, an pschocial well-being of each resident as deterr by reident assessrt plan an individual cae plan. II This wod include th survisory nursing staff

having th necsar skil to supervise direc cae staf in a maer 

consistent with reident rights, inluding th right to be free fran

abe . 

Reccmation No.


H:A shcd coct fur research cocerng long term cae fXlicies which prarte stff stility an pro,ide for adeqate stff-patient ratios necsar to cctrol stress an abe. 

H:A O:ts 

we beieve tht we hae alreay develop an approriate IT for 

enring tht facilities have adeqate an appropriate staff.

metioned in oor rese to Rt:lIlenation lc, KFA wil reqre tht 

facilities have suficient staff to proide for th nees of residents, hoer, it is clea tht increing stf-reident ratios 

alone wil not cotrol abe. Th ootcoriente rerart gives facilities ma flexibility in determg. th ways th wil proide for staff staility an ene tht th nees an rights of residents are 

rrt. We alo note tht any furtr research in ths area wod reqre additional fuing. 
, I
 I.i 

i jl 

CCts of th Heth Care FinC Mnistration (H:A) 

on th OIG Draft rt - Resident e in Nursing Ha: 

Resolving Phyi Abe Oalaints--(QA-06-88-00361) 

OIG recs tht H:A, as part of its coition of participation for

hospitals an nursing ba, shod: 

Recation No.


Reqire al nursing ha stf an hospita rre:Uca personel to report
 al sued incidents of abe to th nursing ha adrator loc law enorcet an to th cetral agcy assigned reibility for resolution of ahe CClaits. 

H:A CCts 

We do not agree entirely with ths reccullenation. We wil rere, effecive O:ber 1, 1990, at 42 c: 483. 13 (for nursing ha), tht al aleged ahe be reJ;rt to th nuing ha adrator or othr official in accrdan with state law. H:A hoita coition participation an th Joint O:sion on Acreditation of Hetbre Organzation stars do not reqire reprting .of ahe. Hcer, the hospita coition of participation do reqre tht hoita follCM state law. We ar not awe of a signficat abe problem in hoitas an do not beieve we ne to revise cu coition of. paicipation. We do not beieve tht th OIG ha dertrate a signicat problem with re to hai ta. 

e:CCIlIl ation No. 

Reqire nursing ha to reprt al ahe inidents to loc law enorcat, th cetral ag assigned reibilty for resolution of 

abe calaits an to th state SUey an Certification Ag. 

H:A CCts 

We do not agree fuy with th recation. Ag, effecive ccber 1, 1990, we wil reqire tht al aleged ince of ahe report to th nuing ha adrator or outside official in 

accrdance with state law. We beieve th is suficient an tht mior abe incidents ca be effecively haed by th adrator witht the nee for invol vert of law enorcat personel. 

Recation No.


Reqire nursing ha to matain report of su inidents of ahe 

an the action taen by th nuing ha. 

H:A CCts 

We agree and beieve tht th DS regation, which reire tht nuing har coct investigation of aleged abe, matain evidence of invesigation, an tae correcive action wh abe is verified, wil satisfy ths reation. 
Page 2


Recation No. 4 

Reqire aCstrators to coct anysis of al incident reprt determe imlication an appropriate acion. 

lCA O:ts 

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

Recation No.


Reqre nursing ha to spify, as pa of th nursing ha residents 

plan of care, a plan to prevent ahe of a reident who is eithr rrtaly or phsicay unle to prote hiherself. 

HCA O:ts 

We agree an believe tht th new reation cor ths issue. The regation at 42 CE 483. 20 proide for a CCrehive assessrt an developt of a plan of care for every resident. Th plan assessrt an plan of care shwd include any spial resident nees, inuding spific 

steps for prevention of ahe, if nasar. 

Recation No.


Reqre nuing ha to proide ongoing rrtoring an caeling
 anloyee su of ahing residents. 

HCA O:ts 

We disagree with th t:Ulenation. Coeling cad be ineqate, an 

we do not beieve tht person su of ahe shwd be alCM to cotine to work with residents whe being caeled. Their bevior 

nut be appropriate or th nu be raed fran th job if extion 

are not net. 

Oter Recations 

HCA agree with th recation for state an loc re5nsibili ties resolution an follCMp tht reqres each state to matain retrievable data for lCA.


In addition, H:A alo agr with th joint ! lIlIendation tht lCA and
 th Adtration on Aging develop ca defintion an categories of ahe for al state an Feeral reprting p.es. We wil 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 

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 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


Administration on Aging Washington, D.C. 20201


TO: Richard po Kusserow 

Inspector General 

FROM: Acting Commissioner on Aging 

SUBJECT: Comments on the OIG Draft Reports on Resident 

Abuse in Nursing Homes


The Administration on Aging (AoA) appreciates theResident 

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 

Abuse Complaints 0 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 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 

Responsibili ties proposes, among other things, that the


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


nursing home abuse The impediments to the collection of
 ty of


such data which the report cites are beyond the capaci 


AoA to overcome Therefore, 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

- 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 ng wi th resident abuse, 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 

patient abuse must have an opportunity to clear their name. This proc 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 enforcement agencies normally only find out about the caes after the fact. A death or 

injury. In many ca 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


BIBUOGRAPHY 

A Consumer Prospective on Quality Care: The Residents' Point of VieW National 

Citizens' Coalition for Nursing Home Reform. 

Chance, Paul Attackig Elderly Abuse Psychology Today, September, 1987. 

Committee on Nursing Home Regulation, Institute of Medicine Improving the Quality 

of Care in Nursing Homes National Academy Press: Washington, D. , 1986. 

Congress of the United States, Congressional Board of the 100th Congress Losing A 

Millon Minds, Offce of Technology Assessment, Washington, DC: Government 

Printing Offce, April, 1987. 

Dalton, Rex State Effort to Close Hospjtal Points Up Industry Problems The San 

Diego Union, October 4, 1987. 

Dolon, Ronald and James E. Hendricks An Exploratory Stuy Comparing Atttues 

and Practies of Police Offcers and Social Service Providers in Elder Abuse and 

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