Elder Abuse in Nursing Homes: An Ecological Perspective

Population trends suggest that the next 20 years will witness a dramatic increase in the adult population aged 65 and older. Projected increases in the elderly population are expected to significantly increase the stress on family and professional caretakers. Stress, in the context of caregiving relationships, is a risk factor associated with increased prevalence of elder abuse in familial and institutional settings. As increasing numbers of older adults are moved from family caregiving to nursing home care settings, it becomes important to identify the pattern of elder abuse risk factors in nursing home facilities. An ecological model is proposed for better understanding the risk factors associated with elder abuse in nursing homes and the complex interaction of individual/person characteristics and contextual factors in institutional elder abuse. An ecological perspective to institutional elder abuse provides a framework for guiding and informing future research on the risk factors of nursing home abuse and, in turn, for the development of effective interventions and relevant social policies.     

Prevention of Elder Mistreatment in Nursing Homes: Competencies for Direct-Care Staff

Existing training on elder mistreatment in nursing homes focuses on detection and reporting of abuse, with little training specifically targeted toward prevention of mistreatment before it occurs. We used qualitative interviews with nursing home staff, policy makers, and related professionals to identify training needs. Based on participant accounts, we drafted a number of competencies essential for caregiver training to prevent mistreatment in nursing homes. Competencies include those dealing with definitions and policies, risks for mistreatment, communication and respect in relationships with residents, and development of a cooperative work environment. Competencies are discussed along with illustrative examples, and implications for practice and policy are addressed.     

Perceptions of Institutional Elder Neglect in Civil Court

Perception of institutional elder neglect (IEN) in civil court was investigated. Experiment 1 participants (N = 162) read an IEN trial summary in which alleged victim testimony was presented or not. Victim testimony increased the likelihood of ruling for the plaintiff, partially mediated by credibility of witnesses for each side. Experiment 2 (N = 68) included a condition with testimony from the victim's floor-mate. Likelihood of ruling for the victim: victim = floor-mate > no testimony, was mediated by perceived credibility of the plaintiff's case. Results are discussed in terms of the importance of alleged victim testimony in IEN cases.     

Long-Term Care Administrators' Perceptions of the Ombudsman Program in the State of Missouri

The presence of a long-term care ombudsman in a long-term care or nursing facility helps prevent abusive or neglectful situations before they start. Almost all Missouri long-term care facility administrators responding to the survey reported that they were aware of the ombudsman program; however, only half currently house an ombudsman in their facility. Respondents aware of the program were significantly more likely to currently accommodate an ombudsman in their facility, and those managing larger facilities were significantly more likely to currently have an ombudsman present. Given the numerous changes in the long-term care system, the need for more ombudsman advocates in this setting is crucial.     

Mom and Pop Versus the Big Boys: Adult Family Homes as Providers of Medicaid-Funded Residential Care

This paper compares assisted living apartments (ALs), adult residential care facilities (ARCs), and small adult family homes (AFHs) for Medicaid residents in Washington State, with particular emphasis on the settings, staffing, services, and policies of AFHs. We targeted for enrollment all residents entering an AFH, ARC, or AL setting on Medicaid/state funding in a three-county area of Washington State. We obtained information on 199 settings, interviewing administrative and direct care providers. AFHs are smaller than ARCs and ALs and less likely to be part of a chain, with no significant difference in staffing ratios of registered nurses and licensed practical nurses. Sixty-four percent of AFH residents were receiving public funds compared to 32% of AL residents. AFHs report admitting residents with more activities of daily living needs, health conditions, and behavior problems. They are less likely to have autonomy-related policies, and they provide more services and fewer activities. While attention should continue to be paid to staff supports, policy and practice should support the continued role of AFHs, which are of special interest because of their potential to provide more homelike, less costly care but with possible trade-offs compared to larger facilities.     

Bringing Assisted Living Services into Congregate Housing

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents—the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.     

The Quality Indicator Survey: Background,Implementation, and Widespread Change

The Quality Indicator Survey (QIS) is the most comprehensive regulatory change to the nursing home survey process since the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). In this article we describe the policy evolution that led to the QIS, summarize the QIS method and implementation, and profile the QIS survey results. Following over a decade of development, in 2007 the Centers for Medicare and Medicaid Services (CMS) began the national rollout of QIS. The intent was to improve consistency in the nursing home survey and to render the survey process more resident-centered and aligned with the intent of OBRA-87. We reviewed policy reports and firsthand accounts from the lead developer of the QIS methodology and leader of the national training contract for QIS. Changes in survey findings are profiled based on analysis of the publicly available Nursing Home Compare database from 2004 to 2010. Nineteen states implemented the QIS between 2007 and 2010, with nearly 20% of U.S. nursing homes receiving QIS surveys in 2010. Nursing homes surveyed with the QIS received more survey deficiencies on average than in the traditional survey; however, average numbers of deficiencies across states became more similar over the early implementation of QIS, with lower-than-average geographic areas experiencing increases and higher-than-average geographic areas experiencing decreases in survey deficiencies. The explicit and structured questioning of residents in the QIS is associated with increases in deficiencies related to choice, dignity, dental care, and nurse staffing. We describe ways in which the QIS affected the regulatory agencies, providers, and resident communities, although these effects are difficult to quantify. CMS's implementation of QIS is a significant step toward a more resident-centered, comprehensive, and consistent survey process. Substantial changes, however, are required not only among regulators but also among nursing homes. We argue that these new expectations and norms surrounding quality assessment and quality assurance are an important component of achieving culture change in U.S. nursing homes.     

Least Restrictive or Least Understood? Waist Restraints,Provider Practices,and Risk of Harm

Since implementation of The Omnibus Budget Reconciliation Act of 1987, restraint use in American nursing homes has reduced dramatically. The reduction in vest restraints has resulted in an increase in “least restrictive” devices such as waist restraints. Although this analysis of U.S. Food and Drug Administration Adverse Event Reporting Data Files found that waist devices pose the same potential risk for asphyxial death as vest restraints, few health professionals and consumers are aware of this outcome. Post-marketing device reporting needs better data quality and surveillance, which can certainly benefit the Centers for Medicare and Medicaid Services in their efforts to regulate and enforce standards of care that reduce deaths and injuries to vulnerable nursing home residents.