Good reasons to take elder abuse seriously.

As an industry that will forever experience the fallout from abuse citations and the ever-increasing demands and expectations of its consumers to prevent abuse, it is necessary to understand and comply with F223 483.13(b), the abuse regulation. As statistically proven by the National Association of Adult Protective Services Administrators (NAAPSA) for the National Center on Elder Abuse (NCEA) (www.elderabusecenter.org), in a 2000 study that included responses from all 50 states plus the District of Columbia and Guam, elder abuse has reached epidemic proportions, with more than 166,000 cases substantiated for that year (of 472,813 reports).

Remember, for starters, that consumers have at their fingertips a treasure trove of knowledge about your facility, including past survey records and measured levels of performance during the past several years. Examples are the Web sites www.MemberoftheFamily.net and www.nursinghomeaction.org, both of which are dedicated to highlighting facilities that have received citations and demonstrated serious resident care issues.

Remember, too, these keys to compliance:

Key 1. Does your facility conduct regular consumer education regarding abuse and neglect? Many people will associate your willingness to discuss such issues with a sense that you have nothing to hide. Providing such information as part of your marketing packet is therefore well advised. Moreover, if you are a drug-free workplace and/or conduct criminal background checks on every prospective employee, highlight those facts. Consumers take comfort in knowing that their loved ones are being cared for by people who are not using drugs and/or do not have a history of criminal activity.

Key 2. The regulation clearly outlines what a facility's policy and procedure must contain to be considered complete and comprehensive. Review your policies and procedures to ensure that the following eight items are addressed:

1. The definition of abuse. Include definitions of verbal, sexual, physical, mental, and involuntary seclusion abuse, as well as of neglect and misappropriation of resident property.

2. Your facility screening procedure. Recent years have seen this becoming more broadly employed. For example, the Illinois Department of Public Health filed in July an emergency rule that would require a police background check on every potential nursing home resident prior to admission. This could be the start of a trend in which background checks continue to broaden their scope to include volunteers, attending physicians, and other people who enter the facility on a regular basis.

3. Types of education offered. There should be an educational track for the resident and one for the employee. For the resident, this would include: review of the definitions of abuse for residents and/or responsible parties at the time of admission and annually, and a review of how to and to whom to report their concerns or situations of suspected abuse, assurance that there is no need for fear of retribution (for example, offering a private, toll-free hot line for making reports), and reassurance that they will be provided with feedback regarding their concerns, both in terms of solutions and information about other agencies where they might obtain assistance. For the employee, training would include orientation and ongoing in-services addressing abuse-prevention practices. Again, review the "without fear of reprisal" stance of your facility and provide education on recognizing signs of caregiver burnout, frustration, and stress, as well as your facility's working definitions of abuse and neglect.

4. Prevention. Keeping a good grievance/complaint report form in a well-advertised location readily available to residents, family, and staff is encouraged. For those submitting such a form, anonymity should be offered. Enhance visibility of the anti-abuse policy by having the local police department conduct staff education on various relevant topics, such as investigative protocols. Also, administrative personnel should conduct regular and unannounced rounds. Residents might be provided a safe in which to keep small prized possessions. Conspicuously located security cameras can be strategically located inside and outside of the facility; hallways, common areas, courtyards, exit and entrance doors, parking lots, and smoking areas are basic starting points for such monitoring.

5. Identification of abuse. Make sure it is understood that, because many residents cannot always make their needs clearly known, identifying possible abuse is the responsibility of all who work within the facility. Suspicious bruising, particularly on the face, arms, abdomen, and shins, should be assessed by nursing and an investigation conducted. Staff should be on alert for patterns, occurrences, and trends that might constitute abuse.

6. Investigation of abuse. A thorough investigation is highly recommended. Ideally, administration should appoint an investigator who understands investigative protocols and the many legal aspects involved, and all phases of the investigation should be kept confidential. An investigation usually consists of a review of the completed grievance/complaint investigation form, review of the documentation in the medical record, and interviews with several parties: the person reporting the incident, witnesses, the resident(s) involved, the attending licensed health professional, staff on all shifts who may have had contact with the resident during the period of the alleged incident, and perhaps with other residents to determine patterns of abuse or multiple occurrences. The investigation should be completed as soon as possible, with the resulting case report provided to administration for final disposition.

7. Protection. Provisions to protect residents from any person suspected of resident abuse must be made. Often the accused individual is removed from the schedule with pay and not allowed back in the facility until the investigation is complete.

8. Reporting. Appropriate agencies should be notified of an alleged abuse as soon as possible. Agencies such as adult protective services, state licensing and certification agencies, and the resident's responsible party should be among those notified. Any person(s) observing an incident of resident abuse or suspecting resident abuse should report it to the person in charge. Alternate reporting options, such as to the corporate office, hot lines, or agencies' toll-free numbers, are understood to be appropriate, as well. Upon receiving a report of abuse, a licensed nurse should be assigned to immediately examine the resident and record findings. In the case of sexual abuse the police department should be notified immediately; in the meantime, do not bathe the resident or wash the resident's clothing or linen. Staff should also recognize that regardless of when an incident occurred, it must be reported, regardless of any lapse of time.

It's important to note that citations written under F223 and F224 are based on a review by the surveying agency as to the facility's adherence to the regulation, not as to whether the abuse occurred. Conversely, your facility may not receive a violation when abuse has been substantiated because it upheld the requirements of the regulation.

Reta A. Underwood is President of Consultants for Long Term Care, Inc. (CLTC). For further information, phone [phone] or visit www.cltcinc.com. Access CLTC's Web site for free sample policies and procedures relating to this topic. To send your comments to the author and editors, please e-mail [e-mail]. To order reprints in quantities of 100 or more, call [phone].