Spotting patient abuse: Signs can be easy to miss
Policies and training protect patients and agency
There is no food in the refrigerator, so the home health aide comments that it is time to go grocery shopping. "Oh no. Sybil takes care of that for me," says the patient. When the aide asks what the patient means about Sybil, her daughter, taking care of grocery shopping, the patient responds, "I give her $500 each week, and she brings me what I need."
$500 for one person with no food in the refrigerator may indicate financial abuse of this patient. What is the home health staff member’s responsibility at this point?
"Financial abuse is the most difficult type of abuse for home health workers to identify because it takes months for signs of the abuse to develop," says Forrest Hong, PhD, LCSW, director of training and education at LivHome, a home care provider in Los Angeles.
"A well-trained home health worker will notice things like unpaid bills, lack of groceries, discussion about a change in a will, and the patient’s defensive or protective behavior about the family member or other caregiver who is supposed to handle finances," he says.
Whether it’s financial, physical, emotional abuse, or even neglect, if a home health worker suspects abuse, it must be reported within 24 hours according to California statutes, Hong says.
"Our agency policy gives our staff members 10 hours to report their suspicions to their supervisor, then agency personnel help the staff member complete the paperwork and ensure the report is made properly," he says. In California, if a staff member who provides service to a client does not report a suspicion of abuse, it is a misdemeanor with a jail sentence of six months or a fine, he adds.
"It is mandatory that every home health agency have a policy that addresses reports of client abuse and that the policy follows state statutes," says Elizabeth E. Hogue, an attorney based in Burtonsville, MD.
While agency management cannot serve as a screening tool to determine whether the report should be filed, most home health agencies require a clinician to report the suspicion to a supervisor so that the agency knows what is being reported and makes sure it is reported accurately and in a timely manner, Hogue says.
In almost all cases, the initial report to the state agency is verbal with a written report faxed after the verbal report, she says. "Make sure your documentation and your written report is specific and focuses on direct observations," Hogue says. "If a clinician suspected that the caregiver was not changing a bed-bound patient’s diapers as often as necessary, the clinician might clean and change the diaper and mark an "X" on one of the tabs at one visit," she suggests. "At the next visit, if the same diaper, with the "X" is still on the patient, it’s a clear indication that the caregiver is not giving the patient proper attention," she says. The report would describe the actions taken by the clinician to determine if the diaper was changed and the clinician’s observations on the second visit, she adds.
"Even after a report is filed, we will send a case manager or social worker to visit the caregiver and patient," says Hong. Some observations of neglect may be a lack of understanding on the caregiver’s part or an inability of the caregiver to provide the care needed, he says. In these cases, other resources are evaluated to help the caregiver, he says.
Document suspicions
It’s important that all home health staff members understand that proper documentation and reporting of abuse may in fact protect them from the same allegations, says Hogue. "If the patient develops eight stage-four pressure ulcers, is it because the home health agency did not monitor the patient and develop an appropriate care plan, or is it because the family caregiver never turned the patient?" she asks. To defend against these questions, nurses need to document how often they move the patient and whether or not the patient is always in the same position when they visit, she adds.
If no action is taken to talk with the caregiver and document the observations of the clinicians, the family members could say the home health agency caused the ulcers as a result of improper care, she says.
Even if you have a clear policy regarding reporting abuse, make sure your staff members understand the policy and that they have received some training related to identifying potential abuse, Hong says. "I suggest using a variety of methods, including updates in newsletters, classes, and reports at staff meetings," he says. "We also require all employees to read our policy on elder abuse and sign it to indicate they understand," he says.
There are several types of abuse and each type has specific indicators that should alert clinicians to the potential for abuse, Hong says. Only the most severe cases of abuse can be identified in one or two visits, so Hong says that clinicians need to stay alert to patterns that might represent abuse. His area of special interest is financial abuse of older people by family members or friends who offer to help with their financial obligations, Hong says.
The only way a home health worker will learn about this type of abuse is by developing a relationship in which the patient trusts him or her enough to talk about things in the patient’s life, he says. "If patients express concern that they no longer have access to their money, or that they don’t understand a new will they have signed, or if personal items in the home are missing, there is a need for further investigation," Hong says.
Home health employees may be reluctant to report abuse because they often continue to see the patient, he says. "These reports are confidential, and they are important to protect patients and home health workers," he adds.
A good, clear policy on accepting gifts or additional cash from patients or their family members is another protection for the home health agency when it comes to financial abuse, Hong says.
"Our policy is that no employee can accept cash or gifts from a patient or family member. We are their employer, not the family, so it is not appropriate for the family to offer any type of bonus," he says.
Prepare carefully for testimony
If the report results in a hearing, be careful about your testimony, Hogue says. "Attorneys like to call home health workers to the stand and treat them as expert witnesses who can offer opinions," she says. "If you are called to report what you witnessed, be sure to answer questions with statements that begin with, "I saw this, or I heard this," she says. Avoid offering opinions as to whether or not the situation you observed constitutes abuse, and don’t offer opinions as to why the situation occurred or what may have happened when you weren’t there, she adds.
The most important thing to stress to employees is that there is no liability for the reporter if the report is made in good faith, says Hogue. She adds, "If it is documented well, actual observations are reported, and the report is not made in anger, the staff member and the agency are protected from liability."
[For more information about reporting abuse, contact:
• Forrest Hong, PhD, LCSW, Director of Training and Education, LivHome, 5900 Wilshire Blvd., Los Angeles, CA 90036. Telephone: (323) 933-5880. E-mail: [email protected].
• Elizabeth E. Hogue, Esq., 15118 Liberty Grove, Burtonsville, MD 20866. Telephone: (301) 421-0143. Fax: (301) 421-1699. E-mail: [email protected].]
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Is Patient Suffering Abuse? Know the warning signs While abuse of a home health patient may be subtle and difficult to identify in one or two visits, home health clinicians need to recognize the different types of indicators that may represent abuse. The following indicators, by themselves, do not necessarily signify abuse or neglect. They may be clues, however, and thus helpful in assessment of abuse. Possible indicators of physical abuse
Possible indicators of psychological/emotional abuse
Possible indicators of financial abuse
Possible indicators of neglect by caregiver
Possible indicators of abuse from caregiver
Source: Reprinted with permission. Elder Abuse Prevention, 1000 MacDonald Ave., Suite C, Richmond, CA 94801. Telephone: (510) 233-3427. Fax: (510) 233-3459. Web site: www.oaktrees.org/elder. |
Resources on Abuse
For more information and resources to help you identify abuse and develop policies, contact the following organizations:
• National Center on Elder Abuse, 1201 15th St., N.W., Suite 350, Washington, DC 20005-2800. Telephone: (202) 898-2586. Fax: (202) 898-2583. E-mail: [email protected]. Web site: www.elderabusecenter.org. The web site contains fact sheets, publications, caregiver resources, state statutes, research, and links to other resources on elder abuse.
• National Committee for the Prevention of Elder Abuse, c/o Amie Cloutier, Matz, Blancato & Associates, 1101 Vermont Ave., N.W., Suite 1001, Washington DC, 20005. Telephone: (202) 682-4140. Fax: (202) 682-3984. E-mail: [email protected]. The organization offers a variety of publications including, Trainer’s Manual: Elder Mistreatment: Ethical Issues, Dilemmas, and Decision-Making, that can be purchased for $25. Other publications for sale are displayed at www.elderabusecenter.org/publication/ncpea.html.
• Clearinghouse on Abuse and Neglect of the Elderly (CANE), Department of Consumer Studies, University of Delaware, Newark, DE 19716. Telephone: (302) 831-3525. Fax: (302) 831-6081. E-mail: [email protected]. The organization offers the nation’s largest computerized collection of elder abuse resources and materials. With more than 3,000 holdings, CANE is able to perform customized searches of more than 100 keywords, producing annotated bibliographies available to the professional communities and the public. To reach the clearinghouse, go to www.elderabusecenter.org/publication/cane.html.
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