Data from the Centers for Medicare and Medicaid Services shows that more than 1.3 million people live in 15,700 nursing homes in the U.S.
Sons and daughters trust nursing home staff to treat aging parents with the utmost care and respect. When a care facility puts profits above resident safety, that’s when a problem becomes an epidemic.
The truth is that 85 percent of nursing homes report some form of abuse or neglect. Inadequate staffing, high turnover rates, and poor training are widespread. Oftentimes these cases go unnoticed, undiscovered or uninvestigated.
According to the National Center on Elder Abuse, there are seven different types of elder abuse, including:
1. Physical Abuse
- Bruises, black eyes, welts, lacerations, and rope marks
- Bone fractures, broken bones, and skull fractures
- Open wounds, cuts, punctures, untreated injuries in various stages of healing
- Sprains, dislocations, and internal injuries/bleeding
- Broken eyeglasses/frames, physical signs of being subjected to punishment, and signs of being restrained
- Laboratory findings of medication overdose or underutilization of prescribed drugs
- An elder’s report of being hit, slapped, kicked, or mistreated
- An elder’s sudden change in behavior
- The caregiver’s refusal to allow visitors to see an elder alone
2. Sexual Abuse
- Bruises around the breasts or genital area
- Unexplained venereal disease or genital infections
- Unexplained vaginal or anal bleeding
- Torn, stained, or bloody underclothing
- An elder’s report of being sexually assaulted or raped
3. Emotional or Psychological Abuse
- Being emotionally upset or agitated
- Being extremely withdrawn and non-communicative or non-responsive
- Unusual behavior usually attributed to dementia (e.g., sucking, biting, rocking)
- An elder’s report of being verbally or emotionally mistreated
- Dehydration, malnutrition, untreated bedsores, and poor personal hygiene
- Unattended or untreated health problems
- Hazardous or unsafe living conditions/arrangements (e.g., improper wiring, no heat, or no running water)
- Unsanitary and unclean living conditions (e.g. dirt, fleas, lice on person, soiled bedding, fecal/urine smell, inadequate clothing)
- An elder’s report of being mistreated
- The desertion of an elder at a hospital, a nursing facility, or other similar institution
- The desertion of an elder at a shopping center or other public location
- An elder’s own report of being abandoned
6. Financial or Material Exploitation
- Sudden changes in bank account or banking practice, including an unexplained withdrawal of large sums of money by a person accompanying the elder
- The inclusion of additional names on an elder’s bank signature card
- Unauthorized withdrawal of the elder’s funds using the elder’s ATM card
- Abrupt changes in a will or other financial documents
- Unexplained disappearance of funds or valuable possessions
- Substandard care being provided or bills unpaid despite the availability of adequate financial resources
- Discovery of an elder’s signature being forged for financial transactions or for the titles of his/her possessions
- Sudden appearance of previously uninvolved relatives claiming their rights to an elder’s affairs and possessions
- Unexplained sudden transfer of assets to a family member or someone outside the family
- The provision of services that are not necessary
- An elder’s report of financial exploitation
- Dehydration, malnutrition, untreated or improperly attended medical conditions, and poor personal hygiene
- Hazardous or unsafe living conditions/arrangements (e.g., improper wiring, no indoor plumbing, no heat, no running water)
- Unsanitary or unclean living quarters (e.g., animal/insect infestation, no functioning toilet, fecal/urine smell)
- Inappropriate and/or inadequate clothing, lack of the necessary medical aids (e.g., eyeglasses, hearing aids, dentures)
- Grossly inadequate housing or homelessness
Studies + Science
Signs of nursing home abuse vary from mild to severe, depending on the length of time and number of staff. Statistics show that 1 in 3 nursing home residents is abused, according to a study from the Special Investigations Division of the House Government Reform Committee. The abuse isn’t always physical; it can also be mental, emotional or financial.
The Department of Health and Human Services defines abuse as “the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.” But neglect is another form of abuse, whether it’s intentional or unintentional.
In The Data
In 2010, a study found that 10 percent of participants reported nursing home abuse in the last year. In the same year, more than half of nursing home staff who participated in the study admitted to engaging in some kind of abuse toward a resident.
In the past six years, the CMS conducted surveys that found more than 330,000 deficiencies in nursing homes. A deficiency is a failure to meet a federal requirement, which is defined by the severity of the deficiency, the potential for harm or the actual harm done.
On top of that, many deficiencies were missed in the initial surveys. The U.S. Government Accountability Office released a report in 2008 that found 15 percent of surveys missed deficiencies for actual harm, and 25 percent missed deficiencies for potential harm.
Pressure ulcers, also known as bedsores, are a major indicator of negligence. Usually starting out small and worsening over time, they can be extremely painful and costly to treat.
The skin breakdown occurs in bony areas that lack substantial fat and muscle, such as the shoulder blades, tailbone, elbows, heels and hips. Individuals who experience difficulty moving have the highest chance of developing pressure sores. For this reason, skin injuries are common in nursing homes and assisted living facilities.
If left untreated, bedsores can lead to serious infections like meningitis, cellulitis and endocarditis. However, pressure sores can be avoided when attentive caretakers learn proper prevention practices.
There are a number of factors that contribute to the development of pressure ulcers, but the majority of individuals who suffer from bedsores have difficulty moving. For that reason, bedsore injuries are common in nursing homes and assisted living facilities.
Elderly residents often remain in the same position for long periods of time, extending the impact of pressure in bony areas. However, immobility is not the only factor that can be a predictor of pressure ulcers. There are a number of factors that contribute to bedsores, including:
- Immobility: The inability to move the body without assistance is the leading predictor of pressure ulcers. Patients with spinal/brain injuries or neuromuscular diseases are particularly vulnerable, but any individual who is bedridden or remains in a wheelchair without frequent repositioning can be affected.
- Age: The risk of bedsores increases as a person gets older. Elderly individuals have reduced blood flow and diminished body fat, which makes their skin more fragile and sensitive to the impact of pressure.
- Malnourishment: A well-rounded diet is essential for the skin and tissue to stay healthy. Proper hydration and nutrition will allow the skin to repair and replenish its cells. If an individual isn’t consuming enough nutrients, their body will be unable to heal.
- Chronic physical conditions: Individuals who suffer from diabetes or artery diseases are also vulnerable. These conditions hinder the body’s ability to receive vitamins from food and oxygen from blood.
- Mental incapacitation: Brain disorders, such as Alzheimer’s, can limit a patient’s ability to ask for help. Some individuals may be unable to seek proper treatment when a bedsore has developed.
- Incontinence: Urinary and bowel incontinence, or the inability to control urine or waste, can leave moisture and bacteria on the skin. Moisture, when coupled with pressure and friction, can cause irritation that leads to skin breakdown.
According to The National Pressure Ulcer Advisory Panel, there are four identifiable stages of pressure sores. The panel describes the sores, ranging from an at-risk injury to dangerously exposed bone and muscle. There is one phase that medical professionals are unable to classify.
Patients and their family members should be aware of the different phases of bedsores in order to ensure optimal levels of health care. Pressure sores begin to affect the skin and worsen over time. Health professionals have classified pressure sore timelines into different stages.
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry, shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation. *Bruising indicates deep tissue injury.
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.
UNSTAGEABLE/ UNCLASSIFIED: FULL THICKNESS SKIN OR TISSUE LOSS – DEPTH UNKNOWN
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.
Federal law requires nursing home staff to take adequate measures to prevent bedsores. Government recommendations maintain that each resident requires two hours of personalized care each day.
Despite genuine attempts to enact policies that would stop the abuse for good, heart-wrenching stories about mistreated patients at elderly care facilities continue to populate the media. Federal agencies and advocacy organizations have tried to put laws in place to positively impact the trend of abuse in nursing homes.
Medicare and Medicaid
Fifty years ago, the U.S Department of Health and Human Services implemented Medicare and Medicaid programs to help fund more than 15,000 nursing homes. If a nursing home wanted to receive federal funding, they had to meet certain requirements. The programs were a national attempt to improve conditions at these facilities.
Measures have been taken to reduce the prevalence of antipsychotic medications in nursing homes, which can seriously threaten elderly patients.
A report was released that showed a large portion of nursing home residents filed for antipsychotic prescriptions. In March 2012, the CMS worked to reduce the amount of unapproved antipsychotics in nursing homes by 15 percent with a December 2012 deadline. The CMS successfully reached the reduction goal in September 2014. They announced a new goal to further reduce the antipsychotic statistic by 25 percent in 2015 and 30 percent in 2016.
The attempts for better quality care continue in recognition and policy efforts as well.
The Agency For Health Care Administration recognized 958 nursing homes for successfully reducing hospital readmissions, lessening antipsychotic medication use and increasing staff stability and patient satisfaction in 2014. In 2015, the organization expanded the goals to reduce negative health care outcomes and improve facilities function and discharge rates.
Laws are continually being updated to encourage better cooperation. The Affordable Care Act has been revised to include compliance and ethics programs, quality assurance, performance improvement requirements and reporting of suspicion and crime requirements. Resident’s rights, facility responsibilities, and updated food and nutrition requirements will be increasingly addressed in the future.
In 2008, Nursing Home Compare was launched. It’s a government-run site that provides one to five-star rankings for more than 15,000 various facilities based on inspections, staffing education level and quality assurance. However, a large majority of the data is self-reported.
The Next Steps
Pressure ulcers, also known as bedsores or decubitus ulcers, develop when recurring friction and continuous pressure breaks down the skin. However, the good news is that bedsores can be prevented.
There are a number of ways to limit the risk of bedsores. Nursing home staff members should be attentive, compassionate and well-trained. In-home caretakers can also learn how to avoid pressure ulcers.
Here’s a checklist to make sure elderly individuals get the care they deserve:
- Risk Assessment: Health care providers should assess each individual to determine the risk of pressure sores. After an individual has been evaluated, caretakers should create a personalized plan to keep bedsores at bay. And always, always get a second opinion.
- Skin Inspection: Check and double check the skin, and then check it again. Look for inflammation, irritation and color/texture changes. Don’t skip the hard-to-reach areas.
- Moisture Reduction: Wet bedding or clothing should be changed immediately. Moisture creates friction and a breeding ground for infection.
- Incontinence Support: Urine is chock-full of dangerous bacteria. Each care facility should purchase incontinence pads, catheters, rectal tubes and sanitary lotions. For some individuals, setting a bathroom schedule might make a tremendous difference.
- Hygiene Assistance: Skin should be regularly cleaned with a gentle soap and lightly patted with a towel. Harsh, beaded scrubs and alcohol-containing products should be avoided.
- Proper Nutrition: Sores take longer to heal if the body is malnourished. Consult a dietician to be sure that each individual is consuming the right amount of healthy foods. Supplements like zinc and vitamin C, in addition to significant intake of water, is the key to achieving optimal health.
- Regular Repositioning: The biggest threat to aging skin is a long-term lack of movement. Movement stimulates blood flow and ensures that all organs receive nutrients and oxygen. People should be repositioned at least once every two hours, regardless of whether they’re in a bed, chair or wheelchair. Set an alarm as a reminder.
- Exercise: Patients should engage in light exercise. Aids can provide assistance to allow bedridden individuals to access their full range of motion. Even something as simple as lifting each arm and holding it up for 10 seconds can stimulate blood flow.
- Redistribution Equipment: A draw sheet or overhead trapeze can help to minimize accidents when moving patients. Additionally, caretakers and facilities should consider investing in an adjustable bed or wheelchair.
- Basic Comforts: Stock the room with a thick mattress, fluffy pillows, cushions and foam padding. Pillows should be placed under the tailbone, shoulders, heels, and elbows. The best way to make sure a resident has what they need is to ask.
Negligence is a crime. Although providing adequate care might seem like a simple task, there are thousands of residents developing pressure sores.
Family members must take an interest in their elder relatives to confirm proper care is being given. Offenses like this often go unpunished unless discovered and reported.
Abuse or neglect can be as obvious as bedsores, malnutrition, dehydration, dosage errors, continued falls, bruises from rough handling, clogged breathing tubes or dirty living conditions. However, it can also be very unclear, like a resident left wandering or the repeated hurtful statements to patients with Alzheimer’s.