Regulations

Objective: Demonstrate knowledge of applicable state and federal regulations.

This tag outlines the scope of social services to be provided by the facility. The entire text of Tag F250 is discussed below.

F250

§483.15(g)(1) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

The Omnibus Budget Reconciliation Act (OBRA) of 1987 requires SNFs (skilled nursing facilities) to provide "medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident" and specifies that "the services provided or arranged by the facility must meet professional standards of quality." This law applies to all residents within the federally certified SNFs.

The OBRA 1987 further states that when any federally-certified nursing facility has over 120 beds, the facility is required to employ, on a full-time basis, a minimum of one social worker. Federal regulations state that this social worker must have at least a bachelors degree in social work, or in another human services field, and 1 year of supervised social work experience in a health care setting working directly with individuals.  For facilities that have 120 beds or less, medically-related social services must still be provided. However, there is no specific requirement that they be performed by a qualified social worker.(this is when most facilities hire a Social Worker Designee) 

The OBRA 1987 also mandates that each nursing home resident have a comprehensive initial resident assessment, as well as periodic assessments using a standard form called the Minimum Data Set (MDS). Under Medicare payment rules, the Centers for Medicare & Medicaid Services (CMS) requires that a 5-day, 14-day, 30-day, and 60-day MDS be completed for all residents. These assessments include psychosocial assessment indicators that guide the preparation and maintenance of psychosocial-related care plans for each resident. Ideally, all identified psychosocial needs are addressed in a care plan, and for all care plans developed, there is documentation that all services are provided.

Intent §483.15(g)

To assure that sufficient and appropriate social services are provided to meet the resident’s needs.

Interpretive Guidelines §483.15(g)(1)

Regardless of size, all facilities are required to provide for the medically related social services needs of each resident. This requirement specifies that facilities aggressively identify the need for medically-related social services, and pursue the provision of these services. It is not required that a qualified social worker necessarily provide all of these services. Rather, it is the responsibility of the facility to identify the medically-related social service needs of the resident and assure that the needs are met by the appropriate disciplines.

“Medically-related social services” means services provided by the facility’s staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. These services might include:

• Making arrangements for obtaining needed adaptive equipment, clothing, and personal items;
• Maintaining contact with facility (with resident’s permission) to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning;
• Assisting staff to inform residents and those they designate about the resident’s health status and health care choices and their ramifications;
• Making referrals and obtaining services from outside entities (e.g., talking books, absentee ballots, community wheelchair transportation);
• Assisting residents with financial and legal matters (e.g., applying for pensions, referrals to lawyers, referrals to funeral homes for preplanning arrangements);
• Discharge planning services (e.g., helping to place a resident on a waiting list for community congregate living, arranging intake for home care services for residents returning home, assisting with transfer arrangements to other facilities);
• Providing or arranging provision of needed counseling services;
• Through the assessment and care planning process, identifying and seeking ways to support residents’ individual needs;
• Promoting actions by staff that maintain or enhance each resident’s dignity in full recognition of each resident’s individuality;
• Assisting residents to determine how they would like to make decisions about their health care, and whether or not they would like anyone else to be involved in those decisions;
• Finding options that most meet the physical and emotional needs of each resident;
• Providing alternatives to drug therapy or restraints by understanding and communicating to staff why residents act as they do, what they are attempting to communicate, and what needs the staff must meet;
• Meeting the needs of residents who are grieving; and finding options which most meet their physical and emotional needs

Factors with a potentially negative effect on physical, mental, and psychosocial well being include an unmet need for:

• Dental /denture care;
• Podiatric care;
• Eye / vision care;
• Hearing services
• Equipment for mobility or assistive eating devices; and
• Need for home-like environment, control, dignity, privacy

Where needed services are not covered by the Medicaid State plan, nursing facilities are still required to attempt to obtain these services. For example, if a resident requires transportation services that are not covered under a Medicaid state plan, the facility is required to arrange these services. This could be achieved, for example, through obtaining volunteer assistance.

Types of conditions to which the facility should respond with social services by staff or referral include:

• Lack of an effective family/support system;
• Behavioral symptoms;
• If a resident with dementia strikes out at another resident, the facility should evaluate the resident’s behavior. For example, a resident may be re-enacting an activity he or she used to perform at the same time everyday. If that resident senses that another is in the way of his re-enactment, the resident may strike out at the resident impeding his or her progress.
• The facility is responsible for the safety of any potential resident victims while it assesses the circumstances of the residents behavior;
• Presence of a chronic disabling medical or psychological condition (e.g., multiple sclerosis, chronic obstructive pulmonary disease, Alzheimer’s disease, schizophrenia);
• Depression;
• Chronic or acute pain;
• Difficulty with personal interaction and socialization skills;
• Presence of legal or financial problems;
• Abuse of alcohol or other drugs;
• Inability to cope with loss of function;
• Need for emotional support;
• Changes in family relationships, living arrangements, and/or resident’s condition or functioning; 
• A physical or chemical restraint.
• For residents with or who develop mental disorders as defined by the “Diagnostic and Statistical Manual for Mental Disorders (DSM-IV),” see §483.45, F406.

Probes: §483.15(g)(1)

For residents selected for a comprehensive or focused review as appropriate:

• How do facility staff implement social services interventions to assist the resident in meeting treatment goals?
• How do staff responsible for social work monitor the resident’s progress in improving physical, mental and psychosocial functioning?
• Has goal attainment been evaluated and the care plan changed accordingly?
• How does the care plan link goals to psychosocial functioning/well-being?
• Have the staff responsible for social work established and maintained relationships with the resident’s family or legal representative?
• [NFs] What attempts does the facility make to access services for Medicaid recipients when those services are not covered by a Medicaid State Plan?

Look for evidence that social services interventions successfully address residents’ needs and link social supports, physical care, and physical environment with residents’ needs and individuality.

For sampled residents, review MDS, section H.

Listed below you will find an example of state regulations that is pertinent to the Social Service Designee (specifics are in bold italics). It is important you find and read these regulations for your specific state.

DEFINITIONS
26-39-100. Definitions.

The following terms and definitions shall apply to all of the department’s regulations
governing adult care homes:

(a) "Activities Director" means an individual who meets at least one of the following
requirements:

• Has a degree in therapeutic recreation;
• is licensed in Kansas as an occupational therapist or occupational therapy assistant;
• has a bachelor's degree in a therapeutic activity field in art therapy, horticultural therapy, music therapy, special education, or a related therapeutic activity field;
• is certified as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body;
• has two years of experience in a social or recreational program within the last five years, one of which was full-time in an activities program in a health care setting; or
• has completed a course approved by the Kansas Department of Health and Environment in resident activities coordination and receives consultation from a therapeutic recreation specialist, an occupational therapist, an occupational therapy assistant, or an individual with a bachelor’s degree in art therapy, music therapy, or horticultural therapy. (this is the qualification you are completing by taking this KDADS approved course)

(b) "Administrator" means an individual who is responsible for the general
administration of an adult care home, whether or not the individual has an ownership interest in
the adult care home. Each administrator of an adult care home shall be licensed in accordance
with K.S.A. 65-3501 et seq. and amendments thereto.

(c) "Adult care home" has the meaning specified in K.S.A. 39-923 and amendments
thereto.

(d) "Adult day care" has the meaning specified in K.S.A. 39-923 and amendments
thereto.

(e) "Advanced registered nurse practitioner" means an individual who is certified by the
Kansas board of nursing as an advanced registered nurse practitioner.

(f) "Alteration" means any addition to, modification of, or modernization of the structure
or usage of a facility.

 (g) "Ambulatory resident" means any resident who is physically and mentally capable of
performing the following without the assistance of another person:

• Getting in and out of bed; and
• walking between locations in the living environment.

(h) “Applicant” means any individual, firm, partnership, corporation, company,
association, or joint stock association requesting a license to operate an adult care home.

(i) "Assisted living facility" has the meaning specified in K.S.A. 39-923 and
amendments thereto.

(j) "Audiologist" means an individual who is licensed by the Kansas department of
health and environment as an audiologist.

(k) "Basement" means the part of a building that is below grade.

(l) “Biologicals” means medicinal preparations made from living organisms and their
products, including serums, vaccines, antigens, and antitoxins.

(m) "Boarding care home" has the meaning specified in K.S.A. 39-923 and amendments
thereto.

(n) “Case manager” means an individual assigned to a resident to provide assistance in
access and coordination of information and services in a program authorized by the Kansas
department on aging, the Kansas department of social and rehabilitation services, or the Kansas
health policy authority.

(o) “Change of ownership” means any transaction that results in a change of control over
the capital assets of an adult care home.

(p) “Chemical restraint” means a medication or biological that meets the following
conditions:

• Is used to control a resident’s behavior or restrict a resident’s freedom of movement;and
• is not a standard treatment for a resident’s medical or psychiatric condition.

(q) "Clinical record" means the record that includes all the information and entries
reflecting each resident's course of stay in an adult care home.

(r) “Complicated feeding problems” shall include difficulty with swallowing, recurrent
lung aspirations, and tube, parenteral, or intravenous feedings.

 (s) "Controlled substance" means any medication, substance, or immediate precursor
included in any of the schedules designated in K.S.A. 65-4105, K.S.A. 65-4107, K.S.A. 65-4109,
K.S.A. 65-4111, and K.S.A. 65-4113, and amendments thereto.

(t) "Day shift" means any eight-hour to 12-hour work period that occurs between the
hours of 6 a.m. and 9 p.m.

(u) "Department" means the Kansas department on aging.

(v) "Dietetic services supervisor" means an individual who meets one of the following
requirements:

• Is licensed in Kansas as a dietitian;
• has an associate's degree in dietetic technology from a program approved by the American dietetic association;
• is a dietary manager who is certified by the board of the dietary managers’ association; or
• has training and experience in dietetic services supervision and management that are determined by the Kansas department on aging to be equivalent in content to the requirement specified in paragraph (2) or (3) of this subsection.

(w) "Dietitian" means an individual who is licensed by the Kansas department of health
and environment as a dietitian.

(x) "Direct care staff" means the individuals employed by or working under contract for
an adult care home who assist residents in activities of daily living. These activities may include
the following:

• Ambulating;
• bathing;
• bed mobility;
• dressing;
• eating;
• personal hygiene;
• toileting; and
• transferring.

 (y) "Director of nursing" means a position in a nursing facility or a nursing facility for
mental health that is held by one or more individuals who meet the following requirements:

• Each individual shall be licensed in Kansas as a registered professional nurse.
• If only one individual serves in this position, the individual shall be employed at least 35 hours each week.
• If more than one individual serves in this position, the individuals shall be employed collectively for a total of at least 40 hours each week.
• Each individual shall have the responsibility, administrative authority, and accountability for the supervision of nursing care provided to residents in the nursing facility or the nursing facility for mental health.

(z) "Full-time" means 35 or more hours each week.

(aa) "Health information management practitioner" means an individual who is certified
as a registered health information administrator or a registered health information technician by
the American health information management association.

(bb) "Home plus" has the meaning specified in K.S.A. 39-923 and amendments thereto.

(cc) "Interdisciplinary team" means the following group of individuals:

• A registered nurse with responsibility for the care of the residents; and
• other appropriate staff, as identified by resident comprehensive assessments, who are responsible for the development of care plans for residents.

(dd) “Intermediate care facility for the mentally retarded” has the meaning specified in
K.S.A. 39-923 and amendments thereto.

(ee) "Legal representative" means an agent acting within the bounds of the agent’s legal
authority who meets any of the following criteria:

• Has been designated by a resident to serve as the resident’s trustee, power of attorney, durable power of attorney, or power of attorney for health care decisions;
• is a court-appointed guardian or conservator authorized to act on behalf of the resident in accordance with K.S.A. 59-3051 et seq. and amendments thereto; or
• if the resident is a minor, is either of the following:
• A natural guardian, as defined in K.S.A. 59-3051 and amendments thereto; or
• a court-appointed guardian, conservator, trustee, or an individual or agency vested with custody of the minor pursuant to the revised Kansas code for care of children, K.S.A. 38-2201 through 38-2283, and amendments thereto, or the revised Kansas juvenile justice code, K.S.A. 38-2301 through 38-2387, and amendments thereto.

(ff) "Licensed mental health technician" means an individual licensed by the Kansas
board of nursing as a licensed mental health technician.

(gg) "Licensed nurse” means an individual licensed by the Kansas board of nursing as a
registered professional nurse or licensed practical nurse.

(hh) "Licensed practical nurse" means an individual who is licensed by the Kansas board
of nursing as a licensed practical nurse and is supervised by a registered professional nurse, in
accordance with K.S.A. 65-1113 and amendments thereto.

(ii) "Licensee" means an individual, firm, partnership, association, company,corporation, or joint stock association authorized by a license obtained from the secretary of
aging to operate an adult care home.

(jj) “Medical care provider” means any of the following individuals:

• A physician licensed by the Kansas board of healing arts to practice medicine and surgery in accordance with K.S.A. 65-28,102 and amendments thereto;
• a physician assistant who is licensed by the Kansas board of healing arts in accordance with K.S.A. 65-28a02 and amendments thereto and who provides health care services under the direction and supervision of a responsible physician; or
• an advanced registered nurse practitioner who is licensed by the Kansas board of nursing in accordance with K.S.A. 65-1113 and amendments thereto and who provides health care services in accordance with article 11 of the Kansas board of nursing’s regulations.

(kk) "Medication" means any “drug” as defined by K.S.A. 65-1626 and amendments
thereto.

(ll) "Medication administration" means an act in which a single dose of a prescribed
medication or biological is given by application, injection, inhalation, ingestion, or any other
means to a resident by an authorized person in accordance with all laws and regulations
governing the administration of medications and biologicals. Medication administration shall
consist of the following:

• Removing a single dose from a labeled container, including a unit-dose container;
• verifying the medication and dose with the medical care provider’s orders;
• administering the dose to the proper resident; and
• documenting the dose in the resident's clinical record.

(mm) "Medication aide" means an individual who has a medication aide certificate
issued by the Kansas Department of Dealth and Environment according to K.A.R. 28-39-169b and
is supervised by a licensed nurse.

(nn) "Medication dispensing" means the delivery of one or more doses of a medication
by a licensed pharmacist or physician. The medication shall be dispensed in a container and
labeled in compliance with state and federal laws and regulations.

(oo) "Non-ambulatory resident" means any resident who is not physically or mentally
capable of performing the following without the assistance of another person:

• Getting in and out of bed; and
• walking between locations in the living environment.

(pp) "Nurse aide" means an individual who has a nurse aide certificate issued by the
Kansas department of health and environment according to K.A.R. 28-39-165 and is supervised
by a licensed nurse.

(qq) "Nurse aide trainee" means an individual who is in the process of completing a
nurse aide training program as specified in K.A.R. 28-39-165 or K.A.R. 28-39-167 and has not
been issued a nurse aide certificate by the Kansas department of health and environment.

(rr) "Nursing facility" has the meaning specified in K.S.A. 39-923 and amendments
thereto.

(ss) "Nursing facility for mental health" has the meaning specified in K.S.A. 39-923 and
amendments thereto.

(tt) "Nursing personnel" means all of the following:

• Registered professional nurses;
• licensed practical nurses;
• licensed mental health technicians in nursing facilities for mental health;
• medication aides;
• nurse aides;
• nurse aide trainees; and
• paid nutrition assistants.

 (uu) "Nursing unit” means a distinct area of a nursing facility serving not more than 60
residents and including the service areas and rooms described in K.A.R. 28-39-162a.

(vv) "Occupational therapist" means an individual who is licensed with the Kansas board
of healing arts as an occupational therapist.

(ww) "Occupational therapy assistant" means an individual who is licensed by the
Kansas board of healing arts as an occupational therapy assistant.

(xx) “Operator” has the meaning specified in K.S.A. 39-923 and amendments thereto.

(yy) “Paid nutrition assistant” has the meaning specified in K.S.A. 39-923 and
amendments thereto. In addition, each paid nutrition assistant shall meet the following
requirements:

• Have successfully completed a nutrition assistant course approved by the Kansas department of health and environment;
• provide assistance with eating to residents of an adult care home based on an assessment by the supervising licensed nurse, the resident’s most recent minimum data set assessment or functional capacity screening, and the resident’s current care plan or negotiated service agreement;
• provide assistance with eating to residents who do not have complicated feeding problems;
• be supervised by a licensed nurse on duty in the facility; and
• contact the supervising licensed nurse verbally or on the resident call system for help in case of an emergency.

(zz) “Personal care” means assistance provided to a resident to enable the resident to
perform activities of daily living, including ambulating, bathing, bed mobility, dressing, eating,
personal hygiene, toileting, and transferring.

(aaa) “Pharmacist” has the meaning specified in K.S.A. 65-1626 and amendments
thereto.

(bbb) "Physical restraint" means any method or any physical device, material, or
equipment attached or adjacent to the resident's body and meeting the following criteria:

• Cannot be easily removed by the resident; and
• restricts freedom of movement or normal access to the resident's body.

(ccc) "Physical therapist” means an individual who is licensed by the Kansas board of
healing arts as a physical therapist.

 (ddd) "Physical therapy assistant" means an individual who is certified by the Kansas
board of healing arts as a physical therapy assistant.

(eee) "Physician" has the meaning specified in K.S.A. 65-28,102 and amendments
thereto.

(fff) "Psychopharmacologic drug" means any medication prescribed with the intent of
controlling mood, mental status, or behavior.

(ggg) "Registered professional nurse” means an individual who is licensed by the Kansas
state board of nursing as a registered professional nurse.

(hhh) “Resident” has the meaning specified in K.S.A. 39-923 and amendments thereto.

(iii) “Resident capacity” means the number of an adult care home’s beds or adult day
care slots, as licensed by the Kansas department on aging.

(jjj) "Respite care" means the provision of services to a resident on an intermittent basis
for periods of fewer than 30 days at any one time.

(kkk) “Restraint” is the control and limitation of a resident’s movement by physical,
mechanical, or chemical means.

(lll) “Sanitization" means effective bactericidal treatment by a process that reduces the
bacterial count, including pathogens, to a safe level on utensils and equipment.

(mmm) “Secretary” means the secretary of the department on aging.

(nnn) "Self-administration of medication" means the determination by a resident of when
to take a medication or biological and how to apply, inject, inhale, ingest, or take a medication or
biological by any other means, without assistance from nursing staff.

(ooo) "Significant change in condition" means a decline or improvement in a resident's
mental, psychosocial, or physical functioning that requires a change in the resident's
comprehensive plan of care or negotiated service agreement.

(ppp) "Social services designee" means an individual who meets at least one of the
following qualifications:

• Is licensed by the Kansas behavioral sciences regulatory board as a social worker;
• has a bachelor's degree in a human service field, including social work, sociology, special education, rehabilitation counseling, or psychology, and receives supervision from a licensed social worker; or
• has completed a course in social services coordination approved by the Kansas Department of Health and Environment and receives supervision from a licensed social worker on a regular basis.

(qqq) "Social worker" means an individual who is licensed by the Kansas behavioral
sciences regulatory board as a social worker.

(rrr) "Speech language pathologist” means an individual who is licensed by the Kansas
department of health and environment as a speech-language pathologist.

(sss) “Working day” means any day other than a Saturday, Sunday, or day designated as
a holiday by the United States congress or the Kansas legislature or governor.
(Authorized by K.S.A. 39-932; implementing K.S.A. 2008 Supp. 39-923 and K.S.A. 39-
932; effective May 22, 2009.)

QUALITY OF LIFE
28-39-153. Quality of life.

Each nursing facility shall care for its residents in a manner and in an environment that
promotes maintenance or enhancement of each resident's quality of life.

(a) Dignity. Each facility shall promote respect of each resident and shall fully recognize
each resident's individuality.

(b) Self-determination and participation. The nursing facility shall afford each resident
the right to:

• Choose activities, schedules, and health care consistent with resident's interests, assessments and care plans;
• interact with members of the community both inside and outside the facility; and
• make choices about aspects of the resident's life that are significant to the resident.

(c) Participation in resident and family groups.

• The facility shall afford each resident the right to organize and participate in resident groups in the facility.
• The nursing facility shall afford each resident's family the right to meet in the facility with the families of other residents in the facility.
• Staff or visitors may attend meetings at the group's invitation.
• The facility shall designate a staff person responsible for providing assistance and responding to written requests that result from group meetings.
• When a resident or family group exists, the facility shall consider the views, grievances, and recommendations of residents and their families concerning proposed policy and operational decisions affecting resident care and life in the facility. The nursing facility shall maintain a record of the written requests and the facility responses or actions.

(d) Participation in other activities. The nursing facility shall afford each resident the
right to:

• Participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility; and
• reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

(e) Activities.

• The facility shall provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests of and promote the physical, mental, and psychosocial well-being of each resident.
• A qualified activities director shall direct the activities program.
• The nursing facility shall employ activities personnel at a minimum weekly average of .09 hours per resident per day.

(f) Social services.

• The facility shall provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
• Any facility with more than 120 beds shall employ a full-time Social Service Designee who:
• is a licensed social worker; or
• (B)(i) meets the qualifications in K.A.R. 28-39-144 (bbb); and
• (ii) receives supervision from a licensed social worker.
• (3) Any facility with 120 beds or fewer shall employ a social services designee. If the social service designee is not a licensed social worker or meets the requirements in K.A.R. 28- 39-144 (bbb) (2), a licensed social worker shall supervise the Social Service Designee.
• (4) The nursing facility shall employ social service personnel at a minimum weekly average of .09 hours per resident per day.

(Authorized by and implementing K.S.A. 39-932; effective Nov. 1, 1993; amended Feb. 21, 1997.)

The Survey Process

Things to remember about the survey:

1. Know your regulations
2. Be friendly and welcome conversation about what you do. Surveyors play an important role in assuring quality of care and quality of life.
3. Have records of participation, calendars from the past three months, bedside logs, resident council information (member list and minutes of meetings), and PR available for review. Present a packet of information (approved by your administrator) to the surveyors when they first get to the facility.
4. Have your office and supplies neatly organized and labeled.
5. Be responsible for your department but do not involve yourself in issues related to other departments. They are better trained to do this themselves, just as you are for the service your department provides.
6. Discussion and clarity are important in communicating what and why you do something. If your treatments follow from your assessments and you have made sure that the treatments are carried out according to the resident care plans, there should be no problem during survey.
7. Be yourself.

Elder Abuse

Every year, tens of thousands of elderly Americans are abused in their own homes, in relative’s homes, and even in facilities responsible for their care. You may suspect that an elderly person you know is being harmed physically or emotionally by a neglectful or overwhelmed caregiver or being preyed upon financially. By learning the signs and symptoms of elder abuse and how to act on behalf of an elderly person who is being abused, you'll not only be helping someone else but strengthening your own defenses against elder abuse in the future.

As elders become more physically frail, they're less able to stand up to bullying and or fight back if attacked. They may not see or hear as well or think as clearly as they used to, leaving openings for unscrupulous people to take advantage of them. Mental or physical ailments may make them more trying companions for the people who live with them.

Tens of thousands of seniors across the United States are being abused: harmed in some substantial way, often by people who are directly responsible for their care. More than half a million reports of abuse against elderly Americans reach authorities every year, and millions more cases go unreported.

Where does elder abuse take place?

Elder abuse tends to take place where seniors live: most often in the home where abusers are apt to be adult children, other family members such as grandchildren, or spouses/partners of elders. Institutional settings, especially long-term care facilities, can also be sources of elder abuse.

The Different Types of Elder Abuse

Abuse of the elderly takes many different forms, some involving intimidation or threats against the elderly, some involving neglect, and others involving financial chicanery. The most common are defined below.

Physical abuse

Physical elder abuse is non-accidental use of force against an elderly person that results in physical pain, injury, or impairment. Such abuse includes not only physical assaults such as hitting or shoving but the inappropriate use of drugs, restraints, or confinement.

Emotional abuse

In emotional or psychological senior abuse, people speak to or treat elderly persons in ways that cause emotional pain or distress.
Verbal forms of emotional elder abuse include:

• Intimidation through yelling or threats
• Humiliation and ridicule
• Habitual blaming or scapegoating

Nonverbal psychological elder abuse can take the form of:

• Ignoring the elderly person
• Isolating an elder from friends or activities
• Terrorizing or menacing the elderly person

Sexual abuse

Sexual elder abuse is contact with an elderly person without the elder's consent. Such contact can involve physical sex acts, but activities such as showing an elderly person pornographic material, forcing the person to watch sex acts, or forcing the elder to undress are also considered sexual elder abuse.

Neglect or abandonment by caregivers

Elder neglect, failure to fulfill a caretaking obligation, constitutes more than half of all reported cases of elder abuse. It can be active (intentional) or passive (unintentional, based on factors such as ignorance or denial that an elderly charge needs as much care as he or she does).

Financial Exploitation

This involves unauthorized use of an elderly person's funds or property, either by a caregiver or an outside scam artist.
An unscrupulous caregiver might:

• Misuse an elder's personal checks, credit cards, or accounts
• Steal cash, income checks, or household goods
• Forge the elder's signature
• Engage in identity theft

Typical rackets that target elders include:

• Announcements of a prize that the elderly person has won but must pay money to claim
• Phony charities
• Investment fraud

Healthcare fraud and abuse

Carried out by unethical doctors, nurses, hospital personnel, and other professional care providers, examples of healthcare fraud and abuse regarding elders include:

• Not providing healthcare, but charging for it
• Overcharging or double-billing for medical care or services
• Getting kickbacks for referrals to other providers or for prescribing certain drugs
• Over or under medicating
• Recommending fraudulent remedies for illnesses or other medical conditions
• Medicaid fraud

Signs and Symptoms of Elder Abuse

At first, you might not recognize or take seriously signs of elder abuse. They may appear to be symptoms of dementia or signs of the elderly person's frailty, or caregivers may explain them to you that way. In fact, many of the signs and symptoms of elder abuse do overlap with symptoms of mental deterioration, but that doesn't mean you should dismiss them on the caregiver's say-so.

General signs of abuse

The following are warning signs of some kind of elder abuse:

• Frequent arguments or tension between the caregiver and the elderly person
• Changes in personality or behavior in the elder

If you suspect elderly abuse, but aren't sure, look for clusters of the following physical and behavioral signs.
Signs and symptoms of specific types of abuse:

Physical abuse

• Unexplained signs of injury such as bruises, welts, or scars, especially if they appear symmetrically on two side of the body
• Broken bones, sprains, or dislocations
• Report of drug overdose or apparent failure to take medication regularly (a prescription has more remaining than it should)
• Broken eyeglasses or frames
• Signs of being restrained, such as rope marks on wrists
• Caregiver's refusal to allow you to see the elder alone

Emotional abuse

• In addition to the general signs above, indications of emotional elder abuse include
• Threatening, belittling, or controlling caregiver behavior that you witness
• Behavior from the elder that mimics dementia, such as rocking, sucking, or mumbling to oneself

Sexual abuse

• Bruises around breasts or genitals
• Unexplained venereal disease or genital infections
• Unexplained vaginal or anal bleeding
• Torn, stained, or bloody underclothing

Neglect by caregivers or self-neglect

• Unusual weight loss, malnutrition, dehydration
• Untreated physical problems, such as bed sores
• Unsanitary living conditions: dirt, bugs, soiled bedding and clothes
• Being left dirty or unbathed
• Unsuitable clothing or covering for the weather
• Unsafe living conditions (no heat or running water; faulty electrical wiring, other fire hazards)
• Desertion of the elder at a public place

Financial exploitation

• Significant withdrawals from the elder's accounts
• Sudden changes in the elder's financial condition
• Items or cash missing from the senior's household
• Suspicious changes in wills, power of attorney, titles, and policies
• Addition of names to the senior's signature card
• Unpaid bills or lack of medical care, although the elder has enough money to pay for them
• Financial activity the senior couldn't have done, such as an ATM withdrawal when the account holder is bedridden
• Unnecessary services, goods, or subscriptions

Healthcare fraud and abuse

• Duplicate billings for the same medical service or device
• Evidence of overmedication or undermedication
• Evidence of inadequate care when bills are paid in full
• Problems with the care facility:
• Poorly trained, poorly paid, or insufficient staff
• Crowding
• Inadequate responses to questions about care

Risk Factors for Elder Abuse

It's difficult to take care of a senior when he or she has many different needs, and it's difficult to be elderly when age brings with it infirmities and dependence. Both the demands of care giving and the needs of the elder can create situations in which abuse is more likely to occur.

Risk factors among caregivers

Many nonprofessional caregivers, spouses, adult children, other relatives and friends find taking care of an elder to be satisfying and enriching. But the responsibilities and demands of elder care giving, which escalate as the elder's condition deteriorates, can also be extremely stressful. The stress of elder care can lead to mental and physical health problems that make caregivers burned out, impatient, and unable to keep from lashing out against elders in their care.

Among caregivers, significant risk factors for elder abuse are

• Inability to cope with stress (lack of resilience)
• Depression, which is common among caregivers
• Lack of support from other potential caregivers
• The caregiver's perception that taking care of the elder is burdensome and without psychological reward
• Substance abuse

Even caregivers in institutional settings can experience stress at levels that lead to elder abuse. Nursing home staff may be prone to elder abuse if they lack training, have too many responsibilities, are unsuited to care giving, or work under poor conditions.

The elder's condition and history

Several factors concerning elders themselves, while they don't excuse abuse, influence whether they are at greater risk for abuse:

• The intensity of an elderly person's illness or dementia
• Social isolation; i.e., the elder and caregiver are alone together almost all the time
• The elder's role, at an earlier time, as an abusive parent or spouse
• A history of domestic violence in the home
• The elder's own tendency toward verbal or physical aggression

In many cases, elder abuse, though real, is unintentional. Caregivers pushed beyond their capabilities or psychological resources may not mean to yell at, strike, or ignore the needs of the elders in their care.

Reporting Elder Abuse

If you are working in a facility, report any signs of elder abuse to the charge nurse. The activity director may also report to the adult care abuse hotline at 1-800-842-0078. If you suspect elder abuse of a friend or neighbor you may report the abuse to Eldercare Locator at 1-800-677-1116 . The person who answers the phone will refer you to a local agency that can help. The Eldercare Locator answers the phone Monday through Friday, 9 am to 8 pm, Eastern Time.

States differ on who is required to report suspected elder abuse (there's no federal standard), though the categories of mandatory reporters are expanding. Typically, medical personnel, nursing home workers, peace officers, emergency personnel, public officials, social workers, counselors, and clergy are listed as mandatory reporters, and that responsibility is spreading to financial institutions and other entities that work with seniors.

If your client, resident, friend or neighbor shows these types of abuse, it is your responsibility to report the findings to the proper authorities. If you find these marks at the facility you work, please start with reporting them to the charge nurse.