Confronting resident abuse and neglect.

An unusual partnership has placed this state in the forefront of combating a national tragedy

It is an act so offensive that most people - including many caregivers in the long-term care community - don't want to acknowledge that it occurs, particularly in a setting where frail and chronically ill elders and disabled people are expected to be free from harm.

"Abuse and neglect." Historically, just the phrase would put long-term care providers on the defensive. But times have changed. Most providers now recognize the devastating impact even one instance of abuse or neglect can have on the confidence of residents and their families and the morale of staff. Providers have also witnessed the torrent of outrage from the public, regulators and law enforcement officials that can be unleashed when a case becomes highly publicized. While few issues are as emotionally charged, there is now almost a universal recognition within the long-term care profession that with the right tools, elder abuse and neglect can and must be prevented.

When the Massachusetts Extended Care Federation (MECF) and the state's Office of the Attorney General launched a collaborative attack on the problem of elder abuse and neglect nearly five years ago, the initiative took some people by surprise: Why would the long-term care provider community put its fate in the hands of the state's leading prosecutor? Conversely, why would the Attorney General of Massachusetts work directly with the industry on prevention rather than focusing simply on prosecution?

But then, the collaborative effort has been anything but typical. Because of providers' and prosecutors' joint commitment to focus on prevention, there have been two statewide conferences and numerous regional workshops convened on the issue, as well as the distribution of a comprehensive two-hour training program and video entitled Keeping Nursing Facility Residents Safe to all nursing facilities in Massachusetts. The training program, which is ongoing, is designed for the initial orientation and ongoing training of all levels of staff.

Most long-term care employees understand that the deliberate striking of a resident constitutes physical abuse, if not assault. What is more difficult to convey is an appreciation of other levels of abuse and neglect. Keeping Nursing Facility Residents Safe is designed to give caregivers a deeper understanding of unintentional and subtle forms of abuse and neglect that may still constitute a violation of the law and a resident's rights. For example, a form of neglect that can result in unintentional harm to a resident might be leaving a resident alone in a bathroom when the care plan indicates the need for assistance. The employee who leaves the resident alone clearly does not intend for that person to come to harm, but if harm occurs in that situation, the law may be blind to the employee's intentions and simply look at his or her actions.

In one module of the training program and accompanying video presentation, the trainer outlines the major areas of abuse, mistreatment and neglect to which a resident might be subjected and then engages participants in a discussion to make certain they understand how these concepts are defined and how the law looks at them. The training program covers physical, psychological and sexual abuse, as well as financial abuse and exploitation, neglect and mistreatment. Providers are also encouraged to make certain that their staff members fully understand the applicable state and Federal laws designed to protect elders in long-term care settings.

The results of the collaborative effort are so far encouraging: According to the Massachusetts Department of Public Health, which regulates and receives complaints about nursing facilities in the state, there has been a 20% reduction in reported cases of abuse since 1994. In addition, the total number of complaints resulting in a valid finding against a certified nursing assistant (CNA) has dropped nearly 50%. Finally, the number of prosecutions has fallen from a high of 31 in 1993 to just 3 in 1997.

As a result of these promising initial results, the American Health Care Association (AHCA) - which represents more than 11,000 long-term care facilities across the country - has endorsed the Massachusetts training program and is distributing it nationwide. In addition, during a meeting of the National Association of Attorneys General (NAAG) held in Boston last year, AHCA and NAAG made a commitment to work on a comprehensive national prevention effort.

As the trend in Massachusetts indicates, a potent course of education and enforcement will go a long way toward reducing the incidence of elder abuse and neglect. Yet, despite the positive trend with that approach, the combination of enforcement and training is not enough to prevent all cases of abuse and neglect from occurring.

A major flaw in the system is that providers around the country do not have the ability to adequately screen candidates seeking employment in their facilities. In Massachusetts, long-term care facilities are permitted to conduct Criminal Offender Record Information (CORI) investigations of job applicants. In addition, MECF has lobbied for legislation that mandates facilities to conduct CORI checks on all prospective employees, with the Medicaid program assuming its portion of the cost for those investigations.

However, even individual state criminal record disclosure laws are not enough. There needs to be a fully funded and staffed Federal nurse's aide registry so that providers are able to access all other state databases to determine if an employment candidate has prior convictions or pending charges in another state. These might include elder abuse, theft, or any crime that would render the individual unsuitable for employment in a nursing facility. Concerns about employee privacy notwithstanding, it is simply unacceptable that an individual previously convicted of elder abuse in one state can hide that fact and travel to another state and secure work in a nursing facility. This constitutes a lit fuse that will eventually explode on an unsuspecting elder and then, eventually, on his/her caregivers.

In his testimony last November before the Congressional Older Americans Caucus, MECF Chairman Steven W. Garfinkle, representing AHCA, told caucus members that he, AHCA and NAAG agreed that a national registry was essential to a strategy of elder abuse prevention. Garfinkle acknowledged that there are issues, such as privacy concerns, that need to be addressed, but that those issues should not prevent the implementation of a system that is designed to help protect elders.

"Both law enforcement and the industry are committed to this effort," Garfinkle said in his testimony. "But even within the partnership, we sometimes approach the issues from different angles. We're not intimidated by that and on many of the issues are in agreement. What we are committed to is trying to find answers to these questions - and finding them soon."

A commitment to education, strict enforcement of state and Federal laws, and a system to screen out job applicants who have a history of abusive behavior are the three prongs of a national strategy that should go a long way toward ending abuse and neglect in long-term care facilities. And the sooner, the better.

Scott Harshbarger is the attorney general of the Commonwealth of Massachusetts. Ned Morse is president of the Massachusetts Extended Care Federation, the state's largest elder care provider organization.