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Elder Mistreatment and the Elder Justice Act

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Nancy L. Falk, PhD, MBA, RN
Judith Baigis, PhD, RN, FAAN
Catharine Kopac, PhD, DMin, RN, CGNP

Abstract

Elder mistreatment is unrecognized, hidden, and underreported. Studies show that health professionals, nurses among them, are largely unaware of the various forms of elder mistreatment that take place and of the proper course of action to pursue when mistreatment is suspected. In this article, we describe elder mistreatment policies, examining them in the light of the United States’ national elder abuse policies with a focus on important provisions of the Elder Justice Act. Next, we review the various types of abuse, the identification of abuse, and the nurses’ role in addressing elder mistreatment. We present an example of a case of physical abuse and conclude by discussing nurses' advocacy role and issuing a call to action, challenging nurses to ‘act now’ to protect the well being of elders.

Citation: Falk, N. L., Baigis, J., Kopac, C., (August 14, 2012) "Elder Mistreatment and the Elder Justice Act" OJIN: The Online Journal of Issues in Nursing Vol. 17 No. 3.

DOI: 10.3912/OJIN.Vol17No03PPT01

Keywords: Elderly, elder abuse, elder mistreatment, public policy, nursing, physical abuse case, adult protective services, Eldercare Locator, U.S. Administration on Aging – National Center on Elder Abuse, eldercare resources, Elder Justice Act, elder safety

...precise incidence and prevalence statistics on elder mistreatment are unavailable due to the absence of national (U.S.) uniform reporting and data collection systems. An estimated 700,000 to 1.2 million elders in the United States (U.S.) annually suffer mistreatment at the hands of others or self; 450,000 new cases are identified each year (Fulmer, n.d.). Despite these alarming figures, our awareness of elder mistreatment is sparse. Available information tends to come from small, non representative samples; agency and caregiver reports; and the criminal justice system (Bonnie & Wallace, 2003). Although recent studies have sought to overcome data-gathering shortcomings by using national samples, precise incidence and prevalence statistics on elder mistreatment are unavailable due to the absence of national (U.S.) uniform reporting and data collection systems (U.S. Administration on Aging - National Center on Elder Abuse, 2005).

Yet recognition and assessment of elder mistreatment is an important component of clinical practice (Fulmer, n.d.). Elder mistreatment is a broad term that encompasses elder abuse, neglect, and exploitation. Elder mistreatment and elder abuse are often used interchangeably because there are many definitions of mistreatment, traceable to statutory definitions that are highly variable and ambiguous. The legal definitions of abuse and neglect vary widely from state-to-state. In this article, the authors will use elder mistreatment and elder abuse interchangeably.

Elder mistreatment is a broad term that encompasses elder abuse, neglect, and exploitation.The purpose of this article is to provide clinicians with essential information about the various forms of elder mistreatment and offer a roadmap for action aimed at protecting or removing the elderly from abusive circumstances. We will describe elder mistreatment policies, examining them in the light of the U.S. national elder abuse policies with a focus on important provisions of the Elder Justice Act. We will also review the various types of abuse, the identification of abuse, and the nurses’ role in addressing elder mistreatment. We will present an example of a case of physical abuse and conclude by discussing nurses’ advocacy role and issuing a call to action, challenging nurses to ‘act now’ to protect the well being of elders.

Elder Mistreatment Policies

This section will provide a brief overview of the elder abuse policies in the Unites States. It will begin with a brief, historical overview of the policy and then describe the key provisions of the U.S. Elder Justice Act.

Historical Overview of Elder Abuse/Mistreatment in the US

...it is only in recent decades that elder mistreatment as a social policy issue has moved to the forefront of health care and social services in the United States. Elders are the wise matriarchs and patriarchs of families and society. However with age and accompanying physical and cognitive decline, elders become increasingly vulnerable to mistreatment. Nevertheless, it is only in recent decades that elder mistreatment as a social policy issue has moved to the forefront of health care and social services in the United States. The passage of Medicare, Medicaid, and the Older Americans Act legislation in the 1960s is illustrative of a shift toward increased awareness of, and attention to, human welfare issues impacting the elderly. During the same decade, Public Welfare Amendments to the Social Security Act authorized funding to states for the establishment of protective services for those elderly with physical and/or mental challenges who were neglected, exploited, or unable to manage personal matters (U. S. Department of Health, Education, and Welfare, State Letter No. 925 as cited in Teaster, Wangmo,& Abetzberger, 2010).

In 1974, Title XX of the Social Security Act authorized the support of protective services to adults 18 years of age and older at all income levels who were suffering abuse, neglect, or exploitation. This legislation stimulated the creation of Adult Protective Services through Social Service Block Grants at the state level. Unfortunately, the block grant funding mechanism resulted in inconsistent and lower than desired funding for adult programs, as states were forced to make tough spending decisions between competing programs for children and adults. In the late 1970s, the U.S. Congress conducted hearings at the national level to move elder mistreatment to the forefront of our awareness. Despite concerted efforts to raise the urgency level of protecting elders from mistreatment, funding declined (Blancato, 2006).

The situation began to improve only in 2003 when Senator John Breaux introduced the Elder Justice Act in the U.S. Senate (Elder Justice Act, 2003). At that juncture, the notion of elder justice, as opposed to elder abuse or elder mistreatment, served as a vehicle to communicate a message that would speak to the broader human rights issue of freedom from abuse and exploitation. That same year, the Elder Justice Coalition was formed, bringing together advocates committed to the reform of social policy for the protection of elders. From 2003 forward, the coalition fought to ensure that the Elder Justice Act would be signed into law.

In March of 2010 an important victory for vulnerable older adults was won when the Elder Justice Act was passed (Public Law 111-148, 2010) in the sweeping health care reform known as the Patient Protection and Affordability Act. Drawing on John Kingdon’s findings related to agenda setting and policy formulation, a case can be made that the recent passage of the Act came about only with ‘the opening of a policy window,’ i.e., the ‘coupling’ of a problem stream (problem identification and recognition), a policy stream (alternatives and proposals by disparate policy communities), and a political stream (change in administration with an accompanying shift in public opinion related to health reform) (Kingdon, 2003). The Elder Justice Act, now a law, thus authorizes the expenditure of the federal funds necessary to implement the law and provide benefits to elders nationwide. 

Elder Justice Act: Key Provisions

The Elder Justice Act of 2009, Title VI, Section H of the Patient Protection and Affordable Care Act (Public Law 111-148, 2010) is historic, social policy legislation. It is widely regarded as the most comprehensive bill ever passed to combat elder abuse, neglect, and exploitation. While the funding process hinges on appropriations, the Elder Justice Act authorizes close to $770 million in spending (2010-2014). Of this total, approximately $500 million has been earmarked for Adult Protective Services (APS) (Public Law 111-148, 2010). 

Although elder justice will continue to be addressed as a state and local issue, the new law provides support and resources from the federal government that were heretofore unavailable. Part I of the Elder Justice Act calls for the formation of an Elder Justice Coordinating Council comprised of federal government representatives charged with the responsibility of administering programs for the promotion of elder justice. The Council is to provide recommendations to the Secretary of the Department of Health and Human Services on issues of abuse, neglect, and exploitation of the elderly. Twenty-seven professionals from the general public, representing various disciplines and offering expertise in research, training, services, practice, coordination, fiduciary, and enforcement issues, are to provide recommendations to the Elder Justice Coordinating Council. The law also makes provision for the establishment of forensic centers in order to support collaborative efforts by legal, medical, social service, and law enforcement agencies for the prevention and prosecution of crimes against the elderly (Public Law 111-148, 2010).

Part II of the Elder Justice Act focuses on the authorization of programs aimed at enhancing long-term care. The most sizeable portion of Part II is devoted to funding state and local APS initiatives for the collection and dissemination of information, development, and sharing of research and best practices, along with the provision of technical assistance to the states. Authorization has been granted to promote programs committed to training, recruiting, and retaining long-term care staff; improving long-term care management practices; and assisting long-term care facilities in acquisition and implementation of electronic health record (EHR) technology (Public Law 111-148, 2010). Authorization for funding has also been granted for programs enhancing the capacity of ombudsmen to report and resolve complaints of elder abuse, neglect, and exploitation. Finally, there are provisions aimed at the protection of residents of long-term care facilities in the form of grants issued to state survey agencies to train individuals who conduct annual surveys and evaluate complaints (Public Law 111-148, 2010).

Types of Abuse

Elder abuse conjures up images of physical wounds... it is important to recognize that elder mistreatment encompasses a broad range of abuses, each of which requires a different type of intervention.  Elder abuse conjures up images of physical wounds, such as black eyes, or scenes where elders are struck by their loved ones or caregivers. Indeed, while such realities exist, it is important to recognize that elder mistreatment encompasses a broad range of abuses, each of which requires a different type of intervention. Self-neglect, for instance, is a form of abuse that helping professionals are often reluctant to report. Often self-neglect is viewed as a symptom of the aging process in individuals who are free to live as they choose.

Financial exploitation is another form of abuse. Because it is not uncommon for adult children to readily take over an aging parent’s finances, helping professionals are reluctant to intervene in such cases. They tend to perceive this type of situation as a family matter where at least family members are involved. Such misperceptions highlight the importance of recognizing and reporting the various types of abuse, as well as the need for investigating professionals to understand that each report requires an individualized assessment and appropriate intervention.

According to the Elder Abuse Forensic Center (Elder Abuse Forensic Center, n.d.), mistreatment of individuals 65 and over can take the form of physical, sexual, emotional/verbal, and/or financial abuse, or any combination thereof, as well as neglect and self-neglect. Each of these types of mistreatment is defined and illustrated by an accompanying scenario under the broad category of abuse described in Table 1.

Table 1. Types of Abuse

Abuse

Willful infliction of physical pain, injury, or mental anguish upon an older adult; or willful deprivation by a caretaker of services considered necessary for physical and mental health (Fulmer & O’Malley, 1987).

Physical Abuse

“Non-accidental use of force that results in bodily injury, pain, or impairment. This includes, but is not limited to, being slapped, burned, cut, bruised or improperly physically restrained” (NY State - Office of Children & Family Services, n.d., definitions of elder abuse page). It sometimes involves intentional misuse of medication.

Scenario: A male resident in a long-term care facility has bruising about the head, neck, and upper right shoulder. An investigation reveals that the man was struck by his aide because the patient ‘bit’ the caregiver. The aide reports that this was the only way to curtail the biting.

Sexual Abuse

“Non-consensual sexual contact of any kind. This includes, but is not limited to, forcing sexual contact with self or forcing sexual contact with a third person” (NY State - Office of Children & Family Services, n.d., definitions of elder abuse page). Inappropriate exposure, inappropriate sexual advances, inappropriate sexual contact, sexual exploitation, and rape all fall within this category of abuse (Elder Abuse Forensic Center, n.d.).

Scenario: An elderly female, long-term-care resident with dementia, reports that a man has been entering her room at night. During one of her two weekly showers, a nursing assistant discovers blood in her underwear and bruising on the resident’s thighs. A sexual assault exam reveals tearing in the perineal area and semen in the vaginal vault.

Emotional Abuse

 “Willful infliction of mental or emotional anguish by threat, humiliation, intimidation or other abusive conduct. This includes, but is not limited to, isolating or frightening an adult” (NY State - Office of Children & Family Services, n.d., definitions of elder abuse page) and sometimes takes the form of abandonment, isolation, or non-communication (Elder Abuse Forensic Center, n.d.).

Scenario: An older adult is confined to a single room in a very large house because her adult daughter is embarrassed by her presence. The mother is given access to the kitchen and family room only when the teenagers have gone to bed and there are no guests in the home.

Neglect

Deprivation of services deemed necessary for maintenance of physical and mental health. Elder neglect is sometimes the result of an inability on the part of an elder to care for him or herself without external assistance or support. It also occurs when the person responsible to provide such support fails to fulfill his or her obligations (Fulmer & O’Malley, 1987). This type of abuse includes abandonment, as well as deprivation of such basic needs as food, water, clothing, housing, or medical care (Elder Abuse Forensic Center, n.d.).

Scenario: An older incapacitated adult lives within two miles of her adult daughter. The adult daughter is aware that her mother is unable to leave home to purchase basic necessities; and the adult daughter has control of the finances. The mother is allotted no spending money and never sees her bank statements. She is denied food, personal care assistance, and a telephone.

Self-Neglect

Self-neglect is “characterized as the behavior of an elderly person that threatens his/her own health or safety” (U.S. Administration on Aging - National Center on Elder Abuse, n.d., definition of elder abuse page). Self-neglect often presents in the case of elders who have aged alone with limited outside contact.

Scenario: The typical self-neglect scenario presents as the elder who has aged alone in place with limited outside contact. As their world contracts, they venture out of their homes less frequently and eventually pay little or no attention to appearance, hygiene, diet, and other basic needs. They are often paranoid and resistant to outside help.

Financial Abuse/Exploitation

Financial abuse/exploitation refers to the act or process whereby an individual or caretaker takes advantage of an older adult for monetary benefit or any other form of personal benefit that results in a gain or profit to the perpetrator (Fulmer & O’Malley, 1987). This might include undue influence to change legal documents, misuse of property, theft, or embezzlement (Elder Abuse Forensic Center, n.d.).

Scenario: An elderly man is persuaded by a middle-aged, female addict to grant access to his savings and checking accounts. Within a six month period, she spends nearly half a million dollars, furnishing a rental apartment and taking trips.


Identification of Elder Mistreatment/Abuse

Screening and assessment for mistreatment are necessary to determine whether an elderly person is being abused, exploited, or neglected by someone or if he/she is unable to provide self-care. Although screening is critical when identifying all types of mistreatment, it is particularly important in the case of self-care. Self-neglect is often overlooked because clients who have difficulty managing instrumental activities of daily living tend to avoid primary care visits and encounters outside the home.

The Medicare program requires that nursing facilities screen and monitor elders for signs and symptoms associated with mistreatment. The American Medical Association (AMA) (2007) has recommended that clinicians screen for elder mistreatment in any clinical setting. The Medicare program requires that nursing facilities screen and monitor elders for signs and symptoms associated with mistreatment (Centers for Medicare & Medicaid Services, 2011). Because they are uniquely positioned to distinguish the signs and symptoms of mistreatment from those of normal aging, clinicians play an important role in the identification of elder mistreatment.

However, it is important that clinicians do not rely solely on reports from suspected victims and/or their caregivers. Frail elders with cognitive impairment are frequently unable to accurately recount abuse. Additionally, in cases when mistreatment is suspected, clients should be interviewed alone because details and circumstances may be misrepresented when a suspected perpetrator is present. Even when the perpetrator is not present, a victim may be fearful to disclose abuse.

The comprehensive geriatric assessment (CGA) is a useful multidisciplinary diagnostic process for identifying elder mistreatment. The comprehensive geriatric assessment (CGA) is a useful multidisciplinary diagnostic process for identifying elder mistreatment. The CGA includes a social, medical, and functional history, along with a physical examination, cognitive screening, and an assessment for mental conditions, particularly depression. Due to the complexity of the CGA, it is best undertaken by a team of professionals. The CGA often enables clinicians to determine whether mistreatment has occurred, in which case subsequent investigation by the appropriate government agency can result in proper identification of elder mistreatment (Fulmer et al., 2004; Wieland & Hirth, 2003).

Addressing Elder Mistreatment/Abuse

Nurses and other mandated reporters can in fact be held liable by both the civil and criminal legal systems for intentionally failing to make a report regarding their experiences with elder abuse. In the many states with mandated reporting requirements, nurses are included among the group of professionals required by law to report any suspected instances of abuse, neglect, or exploitation they encounter while on the job. Nurses and other mandated reporters can in fact be held liable by both the civil and criminal legal systems for intentionally failing to make a report regarding their experiences with elder abuse.

Fortunately, a variety of national, state, and local resources for elder abuse victims are available to guide nurses in addressing possible mistreatment and abuse situations. Among the major organizations committed to facilitating an understanding of elder care issues and offering various forms of assistance are State Boards of Nursing, the National Center on Elder Abuse, Eldercare Locator/Area Agencies on Aging, and the National Long Term Care Ombudsman Resource Center. Each of these resources will be discussed below. Table 2 (found at the end of this section) provides links to these resources.

State Boards of Nursing

...it is a nurse’s professional responsibility to know the reporting provisions of his or her jurisdiction and to report suspected cases of abuse appropriately for the protection of all stakeholders. Boards of Nursing are state governmental agencies responsible for the regulation of nursing practice. These boards protect the public by regulating and ensuring safe nursing practice. One such protection is the presence of mandatory reporting laws. These laws vary from state to state, and it is a nurse’s professional responsibility to know the reporting provisions of his or her jurisdiction and to report suspected cases of abuse appropriately for the protection of all stakeholders. Mandatory reporting laws can be obtained from one’s State Board of Nursing. Links to the various State Boards of Nursing are available on the National Council of State Boards of Nursing website [www.ncsbn.org]. For the benefit of the elderly population, nurses are well advised to report actual or suspected cases of mistreatment, abuse, or neglect regardless of what their state law stipulates.

National Center on Elder Abuse

Under the auspices of the U.S. Administration on Aging, the National Center on Elder Abuse (NCEA) is a national resource center dedicated to the prevention of elder mistreatment. Funded through Title II of the Older Americans Act, the Center partners with national, state, and local organizations to ensure that elders live with dignity and integrity, i.e., free from abuse, neglect, and exploitation. The NCEA provides the following range of services:

  • Training and technical assistance to state and community organizations;
  • Program and policy development assistance;
  • Professional development opportunities including a website, e-newsletter, listserv, and the Clearinghouse on Abuse and Neglect of the Elderly (CANE); and
  • A training library for adult protective services and elder mistreatment.

Additional NCEA initiatives raise public awareness, promote the development of multidisciplinary approaches, and enhance training for professionals in the fields of criminal justice and health care, as well as victims’ services, aging, and financial services (U.S. Administration on Aging - National Center on Elder Abuse, 2005).

The NCEA website is an invaluable resource for nurses and other health professionals, social service professionals, and families who are seeking to gain practical insight into the many facets of elder abuse, neglect, and exploitation. It makes available a host of national, state, and local elder abuse resources via a ‘help’ section featuring a state directory of helplines, hotlines, and referral sources, along with links to contact information for relevant agencies.

Eldercare Locator/Area Agencies on Aging

Eldercare Locator provides vital assistance to older individuals and their families as they seek to utilize public and private services at the local level.With monies from the Older Americans Act, a public service program entitled Eldercare Locator was developed by the U.S. Administration on Aging. Accessible through the NCEA site, Eldercare Locator is a nationwide service useful for identifying Area Agencies on Aging (state and local entities) that make it their aim to connect older individuals and their families with a broad range of services, including caregiver support. The aging services network comprises 56 state units on aging and 650 local Area Agencies on Aging. Eldercare Locator [www.eldercare.gov] provides vital assistance to older individuals and their families as they seek to utilize public and private services at the local level.

Adult Protective Services

The ‘Find Help’ section of the National Center on Elder Abuse website provides information and links to resources spanning a wide range of mistreatment/abuse topics. The Adult Protective Services section contains valuable information about various services. Adult Protective Services (APS) offers elder abuse victims and their families a network of well-coordinated, interdisciplinary social and health services. Unfortunately, since laws and their accompanying regulations were created independently, system users will discover discrepancies between states in terms of service provision. APS growth and development has emerged from the ground up rather than on the basis of research and evidence. Consequently, practice tends to be “pragmatic” or practical in nature (National Adult Protective Services Association, 2010). Adult Protective Services entities are typically divisions within various departments, depending upon the individual state or locale. In some cases, these programs fall under the oversight of county and human service agencies, designated as Departments of Health and Human Services, Social Services, or Family Services. In other states, they are offered through law enforcement agencies under such designations as the Elder Abuse Prosecution Unit, Elder and Dependent Abuse Unit, Family Violence Unit, or similarly designated departments or units.

Long Term Care Ombudsmen: Advocacy and Complaint Resolution

Long term care ombudsmen advocate for residents of nursing homes, board and care homes, and assisted living facilities. The U.S. Older Americans Act specifies that every state is required to have an Ombudsman Program that addresses complaints and advocates for improvements in the long-term care system (National Long Term Care Ombudsman Resource Center, n.d.). Long term care ombudsmen advocate for residents of nursing homes, board and care homes, and assisted living facilities. They provide information on finding appropriate facilities and obtaining quality care. They are prepared to resolve problems and assist with complaints. The U.S. Administration on Aging (AoA) coordinates an ombudsman network consisting of more than 1,300 paid staff and 8,700 volunteers certified to handle complaints. Most state ombudsman programs are housed in their respective state units on aging. In 2008 alone, the Ombudsman Program investigated over 271,000 complaints made by 182,506 individuals and provided information on long-term care to an additional 327,000 individuals (National Long Term Care Ombudsman Resource Center, n.d.).

Table 2. Quick Links to Resources

Center of Excellence on Elder Abuse & Neglect

www.centeronelderabuse.org/about.asp

Elder Abuse Forensic Center

www.elderabuseforensiccenter.com/

Eldercare Locator

www.eldercare.gov/Eldercare.NET/Public/Index.aspx

Elder Justice Act Summary

www.elderjusticecoalition.com/docs/EJA-Summary-772010.pdf

Elder Justice Coalition

www.elderjusticecoalition.com/

National Adult Protective Services Association

www.apsnetwork.org/

National Center on Elder Abuse

www.ncea.aoa.gov/ncearoot/Main_Site/index.aspx

National Committee for the Prevention of Elder Abuse

www.preventelderabuse.org/about/

National Council of State Boards of Nursing

https://www.ncsbn.org/contactbon.htm

National Long-Term Care Ombudsman Resource Center

www.ltcombudsman.org/

Patient Protection and Affordable Care Act

http://thomas.loc.gov/cgi-bin/bdquery/z?d111:HR03590:|TOM:/bss/d111query.html

U.S. House of Representatives

www.house.gov

U.S. Senate

www.senate.gov


Example of the Realities of Physical Abuse: One Nurse’s Story

In this section, one of the authors will share the details of a real elder abuse situation she experienced. This situation began in January of 2009.

After a short course of rehabilitation and physical therapy, my 93-year-old mother was discharged from the rehabilitation setting to her own apartment where arrangements had been made for hospice care to be provided. At that time, she was in a state of terminal agitation. Despite her condition, she was able to ambulate with a walker several times a day as long as someone was at her side. Hospice had agreed to provide care immediately upon her return to her apartment so that Mother would be attended at all times. However, because hospice was short staffed, they contracted with a local agency to provide a licensed practical nurse (LPN) for Mother to assure that continuous coverage would be provided.  

The agency LPN arrived in the evening, providing much needed respite for the family. Early the next morning, the agency LPN called to say Mother had a good night, even though she had awakened three times throughout the night.  During one of those times, while sitting up as the agency LPN rubbed her back, Mother fell forward and hit her head on the over-bed table. According to the agency LPN, Mother had a scratch on her nose and ‘marks’ on her right cheek and above her right eye. The LPN also reported:  “Your mother said she broke her arm,” but was quick to add that she had assured Mother that she was mistaken. No doubt, the agency LPN insisted, Mother was talking about the peripherally inserted central catheter in her left arm. Mother, however, was referring to her other arm, her right arm.

When we arrived on the scene after the LPN left, we were surprised at the extent of the bruising. Both of Mother’s eyes were blackened, and it looked as if her nose was broken. She had a large bruise on her swollen right upper arm, which indeed appeared to be broken. Upon closer examination, we discovered an entirely bruised toe and bruises on both lower legs.  A bloodstained washcloth had been left on the bedroom window sill.

Because Mother’s injuries were far more extensive than reported or charted, we immediately talked with the hospice nurse on duty that day. The hospice nurse indicated that he had not received a report about the injuries. He then contacted his supervisor, who also knew nothing of the incident. The hospice supervisor made a call to the local agency owner, who claimed that she, too, had heard nothing about the injuries. When the hospice supervisor spoke with the agency LPN about the incident, the LPN told the hospice supervisor the same story she had told us. Further tests indicated, however, that in addition to the multiple bruises, Mother's right arm and nose were indeed broken.

None of the agencies responsible for Mother’s care offered advice or help. A call to one of my colleagues... produced for me an eye-opening discovery: as a nurse, I had a professional responsibility to report this incident.  What happened to Mother in the final days of her life not only hastened her end, but made the dying process significantly more painful for her and for all of us. At the very least, the individual responsible for her care failed to accurately report an incident (verbally or in chart form) that had resulted in severe injuries. Still worse, the individual charged with her care may have fallen asleep, left the apartment with Mother unattended, or simply failed to accompany her as she was walking or moving around. In any event, the LPN’s negligence resulted in multiple injuries. What was to be done? None of the agencies responsible for Mother’s care offered advice or help. A call to one of my colleagues, a geriatric nurse practitioner and co-author of this article, produced for me an eye-opening discovery: as a nurse, I had a professional responsibility to report this incident.

On her advice, I called the Area Office on Aging and was referred to the State Department of Aging 24-hour Elder Abuse hotline. The person covering the hotline took the relevant information from me and forwarded it to the director of our county’s Adult Protective Services (APS) Unit. Within 24 hours, I heard from the APS director, who told me to file a report with the local police and get x-rays of mother’s right arm and face. Both a police officer and an APS worker came to Mother’s apartment and collected information for their respective reports. In February 2009, I filed a Statement of Complaint against the LPN to the Professional Compliance Office of the Department of State. I asked for assurance that this LPN would be reprimanded and that appropriate action would be taken to ensure that nothing like this would happen to anyone else in the future.

Subsequently, I contacted the attorney in the Professional Compliance Office every few months for an update. In June 2011, I learned that the attorney wanted copies of the x-rays in addition to the x-ray reports that had been part of the original Statement of Complaint. The necessary Authorizations to Release Information were obtained and sent in August 2011 to a local investigator from the Bureau of Enforcement and Investigation of the Department of State (the same investigator who had conducted the initial investigation after my complaint was filed in 2009). When I spoke with him on November 4, 2011, he told me his report was complete and had been sent to the attorney at the Department of State Professional Compliance Office the week before. He said the attorney would review the new information and send the complete report to the Board of Nursing for review at their monthly meeting. I was to be notified when a determination was made. In March of 2012, the case against the LPN was closed. There was insufficient evidence of a violation of the applicable licensing law. The information on file will be kept on file in a database so it can be determined if a problematic, repeat pattern of such situations for this LPN is noted.

An important first step is to go to the National Center for Elder Abuse website, where you can find individual state information, including such information as government agencies, state laws, and state-specific data and statistics.  Reflecting on this incident, it is important to remember that appropriate reporting of elder mistreatment varies from state to state. An important first step is to go to the National Center for Elder Abuse website [www.ncea.aoa.gov/], where you can find individual state information, including such information as government agencies, state laws, and state-specific data and statistics. The site provides ample information to assist anyone seeking to report abuse or to learn about the types of services available to families, caregivers, and advocates. The site also gives state-specific telephone numbers for local contact information in most jurisdictions.

The Advocacy Role

Nurses comprise the largest segment of health care providers in the US, totaling over three million nationwide. Because nurses provide care in homes, health systems, and other facilities serving the elderly, they are in a position to advocate on behalf of elderly patients in a wide variety of roles. At the bedside, the nurse’s role includes serving as the patient's eyes and ears in order to ensure that care is provided in a safe manner. Bu and Jezewski (2007) identified three core attributes of patient advocacy as safeguarding of patients’ autonomy, acting on behalf of patients, and championing social justice in the provision of health care. Although patients are encouraged to assume primary responsibility for their own health, nurses may need to assume this responsibility when patients are unable to do so themselves. In doing so, nurses champion social justice as they actively engage in effecting change for the benefit of patients, communities, and societies (Bu & Jezewski).

Nurses can also advance the policy agenda for the elderly by learning about the policy process and stepping forward to speak up on behalf of the elder population.Nurses can also advance the policy agenda for the elderly by learning about the policy process and stepping forward to speak up on behalf of the elder population. Policy leaders in the area of aging encourage nurses to engage in the following activities:

  • seek out aging-friendly legislators who are likely to devote time and resources to the concerns of the aged;
  • identify knowledgeable and trustworthy professionals in policy circles and establish rapport with them;
  • become knowledgeable regarding aging and health-related matters and provide reliable information to these individuals in-order-to move the elder policy agenda forward;
  • work at multiple levels (local, state, and national) to expand this scope of influence; and
  • be aware of the importance of ‘windows of opportunity’ that provide ready support at just the right time (Hinrichsen et al., 2010).

One of the authors has interviewed Bob Blancato, who has served as the National Coordinator of the Elder Justice Coalition since 2003. Mr. Blancato’s contributions to the Coalition are clearly not limited to his comprehensive understanding of the challenges of elder justice. Rather he also demonstrates an in-depth sensitivity to, and understanding of the critical role played by nurses in our society, an understanding imparted by his mother who was a registered nurse (R. Blancato, personal communication, August 17, 2010).

Mr. Blancato has observed that professional nurses have regular contact, and often established relationships, with elders and their families. Hence they are well-positioned to educate the community. These educational roles could include helping others to recognize when a situation constitutes abuse and, thus, when it should be reported; training caregivers so they are better prepared to take on caregiving responsibilities; and providing education about the need for potential resources, such as respite care, including short-term, temporary relief for caregivers (R. Blancato, personal communication, August 17, 2010).

In addition to opportunities to educate, nurses have ample additional opportunities to advocate on behalf of elders. Despite authorization of spending for elder abuse programs, the implementation of these programs is subject to the appropriations process, whereby Congressional representatives determine how the annual budget is to be spent. Nurses are encouraged to take every opportunity to raise greater awareness of the issues of elder mistreatment and the need for funding. Three groups in particular should be contacted: new members of Congress, U.S. Senators and Representatives serving the nurse’s home state, and Congressional Appropriations Committee members. Contact can be made in person or by phone, e-mail, or written communication. For optimal effectiveness, it is recommended that nurses include meaningful and moving local anecdotes that would serve to inform policy makers about the importance of providing support for elder protection activities and programs.

Given the many competing priorities in the midst of health care reform, it is important to make the case for elder care appropriations. The potential influence of nurses reaches beyond the elected officials of their geographic regions. Nurses can impact the policy process at the federal level by contacting members of the Appropriations Committees in the U.S. Senate and House of Representatives. Given the many competing priorities in the midst of health care reform, it is important to make the case for elder care appropriations. Nurses are encouraged to take a similarly active role to influence elder abuse policies, procedures, and resource allocation at state and local levels.

The Elder Abuse Act was signed into law in 2010 and was made possible by individuals committed to improving the quality of life for our aging population. As the largest group of health care providers in this country, nurses are poised to make a substantial difference by actively addressing elder abuse and mistreatment issues within both the clinical environment and the public policy arena. Reflecting upon the challenges and accompanying opportunities, nurses need to ask themselves, “What can I do today to make a difference tomorrow?”

Conclusion: A Call to Action for All Nurses

Elder mistreatment is a widespread and significant challenge facing elders and their families today. This article was written to raise the visibility of the elder mistreatment problem and to provide nurses, from all backgrounds and in all settings, a comprehensive understanding of elder mistreatment, including a historical perspective, definitions of the types of abuse, a legislative overview, comprehensive geriatric assessment insights, mandated reporter information, and quick links to connect nurses to resources so they are well-positioned to take action.

It is every nurse’s responsibility to protect the health and well being of our aging population... Nurses who do not provide direct care are not ‘off the hook.’  It is every nurse’s responsibility to protect the health and well being of our aging population. We challenge all nurses in their respective caregiving roles to make the time and effort to learn how to assess for mistreatment, abuse, and neglect, and to perform assessments when caring for elderly patients. Depending upon a nurse’s role, this might be limited to a physical assessment, or more ideally, expanded to include assessment for potentially related factors, such as abusive caretakers, low social support, mental disorders, and alcohol or drug abuse (Capezuti, 2011). Nurses who do not provide direct care are not ‘off the hook.’ They, too, have a role to play. All nurses are encouraged to call their Congressional representatives today to seek support for Elder Justice at the federal level. Call them again and again, particularly during budgeting and the appropriations process, and reiterate your message. A regular, well-articulated message will keep the issue in the forefront of their activities. Do not hesitate to ask your elected officials and their staff to appropriate funds to support implementation of the Elder Justice Act. Passing the law is a positive first step. Appropriations are needed, however, to implement this vital and underfunded initiative. We ask you to reach out, as soon as today, to advocate on behalf of elders and their families.

Authors

Nancy L. Falk, PhD, MBA, RN
E-mail: nfalk@gwu.edu

Dr. Falk is an Assistant Professor and founding faculty member of The George Washington University School of Nursing in Washington, DC. She served as the John Heinz Senate Fellow (2004-2005) supporting the work of Jeff Bingaman (New Mexico) on the Health, Education, Labor and Pensions Committee and the Senate Finance Committee. Dr. Falk is active in Sigma Theta Tau International, Gerontological Society of America, and other key nursing and aging organizations.  Her current work in healthcare quality, funded in part by the Robert Wood Johnson Foundation (RWJF) and the Agency for Healthcare Research and Quality (AHRQ), is forcused on patient engagement.  She received her BSN from Alfred University in Alfred, NY; her MBA from the University at Buffalo, The State University of NY; and her PhD from George Mason University, Fairfax, VA.

Judith Baigis, PhD, RN, FAAN
E-mail: baigisj@georgetown.edu

Dr. Baigis is a Professor Emerita at Georgetown University School of Nursing & Health Studies in Washington, DC. She has been a public health nurse for decades and is also the research participant advocate on the Clinical Research Unit, Georgetown-Howard Universities Center for Clinical and Translational Science. In addition, Dr. Baigis has been responsible for the health and welfare of five nonagenarians in her family. Her recent experience caring for one of them was the impetus for her contribution to this article. Dr. Baigis received her RN diploma from Geisinger Medical Center in Danville, PA and her BSN, MA, and PhD degrees from New York University, New York, NY.

Catharine Kopac, PhD, DMin, RN, CGNP
E-mail: ckopac@marymount.edu

Dr. Kopac is an Associate Professor and the Chair of the Graduate Nursing Programs at Marymount University in Arlington, Va. She has focused on the care of older adults in acute, long-term, and community care settings since the mid-1970s. She has maintained a clinical practice as a nurse practitioner, ethicist consultant in Adult Protective Services (APS) in Fairfax County, Virginia, for the past ten years. Dr. Kopac’s commitment to APS has inspired her to explore the implications of the new healthcare legislation for vulnerable older adults. Her BS and MN degrees were awarded by Penn State University (State College, PA) and her PhD degree by the University of Maryland in College Park, MD.

References

Bonnie, R. J. & Wallace, R. B. (Eds.). (2003). Elder mistreatment, abuse, neglect and exploitation in an aging America. Washington, DC: National Academies Press.

Bu, X., & Jezewski, M. A. (2007). Developing a mid-range theory of patient advocacy through concept analysis. Journal of Advanced Nursing, 57(1), 101-110.

Capezuti, E. (2011). Recognizing and referring suspected elder mistreatment. Geriatric Nursing, 32 (3), 209-211.

Elder Abuse Forensic Center. (n.d.). What is elder abuse?  Retrieved from www.elderabuseforensiccenter.com/pdf/eafc_whatiselderabuse.pdf

Elder Justice act, U.S. House of Representatives, 108 sess. (2003).

Fulmer, T. (n.d.). Elder mistreatment: Training manual and protocol. Retrieved from http://hartfordign.org/uploads/File/Fulmer_EM_full.pdf

Fulmer, T., & O'Malley, T. (1987). Inadequate care of the elder: A health care perspective on abuse and neglect. New York: Springer Publishing.

Hinrichsen, G. A., Kietzman, K. G., Alkema, G. E., Bragg, E. J.,… Zerzan, J. (2010). Influencing public policy to improve the lives of older Americans, The Gerontologist, 50 (6), 735-743. doi: 10.1093/geront/gnq034

Kingdon, J. W. (2003). Agendas, alternatives, and public policies. New York: Addison-Welsey Educational Publishers.

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National Long-Term Care Ombudsman Resource Center. (n.d.) About ombudsmen. Retrieved from www.ltcombudsman.org/about-ombudsmen

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Teaster, P. B., Wangmo, T., & Abetzberger, G. J. (2010). A glass half full: The dubious history of elder abuse policy. Journal of Elder Abuse & Neglect, 22, 6-15.

U.S. Administration on Aging - National Center on Elder Abuse. (2010). About NCEA. Retrieved from www.ncea.aoa.gov/NCEAroot/Main_Site/Index.aspx

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Weiland, D & Hirth,V. (2003). Comprehensive geriatric assessment. Cancer Control. 10(6), 454-62.


© 2012 OJIN: The Online Journal of Issues in Nursing
Article published August 14, 2012


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