Abuse and neglect in long-term care facilities

September 2005- The following is an excerpt from a commentary by Charmaine Spencer, LL.M. Charmaine is a Research Associate at the Gerontology Research Centre, Simon Fraser University, Vancouver, and an Adjunct Professor in the Department of Gerontology.

What types of abuse can occur in institutions?

Any type of abuse or neglect of older adults that occurs in the community may happen in institutional settings too. This can include physical abuse or neglect, emotional abuse or neglect, financial abuse, sexual abuse, violation of rights, or systemic abuse. The way in which the abuse or neglect is manifested in institutions may be somewhat different than in the community. Restraints, neglect, violation of rights, and systemic harms are more common matters identified by residents, family members, and advocates. In institutional settings, some forms of abuse are not always obvious. Subtle emotional harms may occur such as treating older people like children and disregarding their wishes. Violations of health care or personal rights are commonplace occurrences in some long-term care facilities.

For example, institutional advocates note it is not uncommon for residents of long-term care facilities to complain that they are not allowed to leave facilities on their own. Some operators will not permit competent residents of a long-term care facility to leave without being "signed out" by a responsible third party, even though this is a clear violation of law. Contractual terms that violate residents' rights are also routine in some facilities. As one legal advocacy group has noted, most people have no idea what the law allows long-term facilities to do or not do. As a result, most people would not know an illegal term in an admission contract when they saw it, and even if they did, they have little power to change it.

Paternalism, "administrative efficiency," "risk management," as well as everyday practices (“the way things are done here”), and lack of sensitivity may create abusive or neglectful situations for older adults in long-term care facilities. Systemic forms of abuse or neglect may occur in these settings (eg, “routine use” of incontinence briefs instead of helping the senior to the washroom). The practices may develop for staff convenience or frequently because the facility does not have enough staff. Systemic neglect will be commonplace in institutional settings where there is insufficient staffing to meet the residents' needs.

Other types of abuse or neglect may include abuse through over-medication or under-medication, abuse in the inappropriate use of physical or chemical (medication) restraints, and thefts of residents' personal property because of lack of security. Some forms of institutional abuse violate older people's rights to accept or decline treatment (for example, placing a “do not resuscitate” order on medical records without consulting with the older adult or the person's family, or overriding a mentally capable senior's personal health decisions).

The first, middle and last steps in abuse prevention

At a policy level, it is becoming increasingly common to hear that there is “zero tolerance” for abuse or neglect occurring in institutions, however, effective prevention requires more than rhetoric. It typically involves multiple strategies, including a resident-focused model of care and support that meets the residents' physical, psychological, social and spiritual needs. it means recognizing the involvement of residents, families, friends, staff, administration, and others in the ongoing improvement of the quality of care. It also means having the appropriate physical environment. Abuse and neglect prevention also requires employee screening (both for criminal records and suitability for working with vulnerable persons), adequate oversight including unannounced inspections, and effective methods of enforcing compliance. Prevention of systemic abuse and neglect requires, in part, adequate levels of funding for care in the institutions. In particular, this means earmarking funding increases so that they are used specifically to improve the staff-to-resident ratio and the wages of front-line workers, so to encourage the best employees, as well as reduce staff turnover. A positive approach from the provider or operator is central not only to preventing abuse or neglect, but also to appropriately addressing it, if it arises. When the operator creates a positive work environment and culture, and sets the tone from upper to lower level management, most problems can be addressed effectively within the facility at the earliest point possible. An important part of overall abuse and neglect prevention involves putting the residents' needs first in all aspects of care and support. In a supportive environment, creating an abuse-free environment becomes an integral component of all the tratining, policies, and practices of the facility.

All facilities should have a specific process (a “protocol”) for dealing with abuse or neglect situations. If abuse or neglect occurs, a positive approach means the provider or operator assures the abused resident's emotional and physical safety immediately, and addresses any longer standing trauma that may occur. It also involves openness with family or other key contact person about the incident and steps being taken, as well as providing fairness to the staff member under investigation. In a positive environment, a provider or operator will ensure that the administration does not directly or indirectly prevent employees from speaking to authorities about a legitimate concern.

Residents' bills of rights (although not determinative of all the rights the resident has) and a code of conduct may help generate the right atmosphere and guide employees to making appropriate decisions.

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