Provincial Adult Abuse Prevention Program for Residential Facilities/Nursing Homes

1. Provincial Adult Abuse Prevention Program for Residential Facilities/Nursing Homes Ginette-Marie LeBlanc August 2009

2. Goals and objectives of the program The Government of New Brunswick continues to strive towards a society in which all persons can live safely, with dignity and respect. As part of the Government’s vision that all New Brunswick families must live in a secure, nurturing environment free of abuse and violence we are launching and Adult Abuse Prevention Program for Residential Facilities/Nursing Homes. As the Adult Protection Training Consultant, I offer workshops to owners, operators and staff of residential facilities/nursing homes within the province with the goal of minimizing the risk situation for elder abuse.

3. Agenda -Adult Protection mandate  -Definition  -Profile of the victim  -Profile of the abuser  -Types of abuse/neglect  -Indicators of abuse/neglect  -Precipitating factors of abuse/neglect  -Violence in residential facilities  -Provincial statistics  -Relationship of trust between client and caregiver/Position of authority  -Role and responsibilities of reporting abuse/neglect  -Prevention mechanisms  -Vision for a collective response

4. Provincial facilities Nursing homes: 62 Residential facilities: 497

5. Adult Protection Mandate THE MANDATE of the Adult Protection Program, defined in subsections 34(1) to 42(2) of the Family Services Act and amendments thereto, is limited to the delivery of services to disabled adults and to elderly persons (65 years of age or over) who are victims of abuse or neglect or are in danger of being victims of abuse. The legislation requires that all situations of suspected abuse/neglect of a senior or disabled adult be investigated.

6. Definition The National Clearinghouse on Family Violence defines abuse of older adults as: • “Any action that takes advantage of a relationship between the health care worker and the older adult.”

7. Profile of the victim Seniors who are at increased risk of abuse include: • Older seniors • Female • Isolated seniors • Dependant seniors with disabilities • Seniors with reduced cognitive capacity • Seniors who caregivers have a drug or alcohol problem (National Advisory Council on Aging)

8. Profile of the victim (cont.) • Any type of disability appears to contribute to higher risk of victimization but intellectual disabilities, communication disorders, and behavioral disorders appear to contribute to very high levels of risk • Having multiple disabilities (e.g., intellectual disabilities and behavior disorders) result in even higher risk levels(Sullivan & Knutson)

9. Profile of the victim (cont.) • Seniors who live in long-term health care facilities do so as a result of their inability to provide for their own needs, which renders them physically, psychologically, financially and socially vulnerable to potential mistreatment • According to the report, seniors living in institutions are particularly vulnerable to abuse due to a lack of institutional resources and difficulties faced by health care workers. (National Clearinghouse report)

10. Profile of the abuser Most abuse carried out against seniors is perpetrated by someone known to the victim. It is often a: • Family member • Friend • Caregiver • Landlord • Facility staff (Special Senate Committee on Aging)

11. Types of abuse/neglect Psychological/Emotional Abuse Physical Abuse Sexual Abuse Financial Abuse/Exploitation Chemical Abuse Neglect Self neglect (Adult Victims of Abuse Protocols)

12. Indicators of abuse/neglect General Indicators • Recurring physical ailments with no apparent somatic base • Eating disorders • Extreme, unusual behaviour (aggression, compliance, depression, or withdrawal) • Unusual fear of a particular person or people • Sudden change in feelings about a particular person or place • Nightmares and sleep disturbances • Self-destructive behaviour such as drug/alcohol abuse, self-mutilation or running away • Lack of attachment to caregivers • Compulsive lying and/or confusion regarding personal reality (i.e., dissociation, multiple personalities) • Regression to infantile behaviour

13. Indicators of abuse/neglect (cont.) Chemical Abuse • Over-sedation, reduced physical/mental activity, groggy, confused, pills scattered about may be signs of inappropriate use of drugs, • Reduced/absent therapeutic response to prescribed treatment may be the result of under-medication • Failure to fill prescriptions • If the caregiver is a substance abuser, he or she may be giving drugs or alcohol to the person he/she is caring for

14. Indicators of abuse/neglect (cont.) Neglect • Malnourished, excessive weight loss, lack of groceries/food supplies, empty cupboards. • Emaciated, no dentures, dehydration, mouth sores, confusion may be signs of withholding of nutrition and fluids • Impaired skin integrity, bed sores, rashes, urine burns, soiled linen, unkempt appearance may be signs of inadequate hygiene, personal care • Clothes in poor repair or dirty, inappropriate for season, bug infestation, insufficient clothing • No glasses or hearing aid

15. Indicators of abuse/neglect (cont.) Neglect • Dangerous environment may be the result of a lack of safety precautions being taken and lack of adequate supervision • Unattended, tied to chair/bed • Wandering alone without needed supervision • Not taken to the doctor or dentist/therapist may be the withholding of medical/treatment services • Deserted/rarely seen outside place of residence • Padlocks on doors (bedroom, where food is kept) • Lack of attention to health care needs may include: •  Prevention of access to health care services • inappropriate hospital discharge • inappropriate transfer within an institution - care provider attitudes/lack of understanding, custodialism, and paternalism

16. Indicators of abuse/neglect (cont.) Self Neglect • Absence of necessities including food, water, heat • Inadequate living environment evidenced by lack of utilities, sufficient space, and ventilation • Animal or insect infestations; many pets and mostly in poor health • Signs of medication mismanagement, including empty or unmarked bottles or outdated prescriptions • Housing is unsafe as a result of disrepair, faulty wiring, inadequate sanitation, substandard cleanliness, or architectural barriers • Poor personal hygiene including soiled clothing, dirty nails and skin, matted or lice infested hair, odours, and the presence of feces or urine • Unclothed, or improperly clothed for weather • Bedsores • Skin rashes • Malnutrition

17. Indicators of abuse/neglect (cont.) Self Neglect (cont.) • Dehydration, evidenced by low urinary output, dry fragile skin, dry sore mouth, apathy, lack of energy, and mental confusion • Untreated medical or mental conditions including infections, soiled bandages, and unattended fractures • Absence of needed dentures, eyeglasses, hearing aids, walkers, wheelchairs, braces, or commodes • Exacerbation of chronic diseases despite a care plan • Refusal of medical attention when needed • Worsening dementia • Expresses unrealistic expectations about their care (e.g. claiming that their care is adequate when it is not or insisting that the situation will improve) • Hording of money, food, possessions • Squandering or giving away money • Failure to pay bills

18. Indicators of abuse/neglect (cont.) Physical Abuse • Unexplained loss of hair, abrasions, bruises, burns, bumps, contusions, falls, fractures, • Dislocations, grip marks, bites, haematomas, immobility, infections, internal injuries, • Lacerations, pain, restricted movement, rope marks, swelling, tenderness, skin ulcers, welts • Unusual patterns of bruises, e.g., in the shape of objects such as belts or hairbrushes or grip marks in the shape of fingers or hands, muscle contractures, immobility, shuffling, weakness • Pushing, pulling or rough handling of the individual • Unusual markings on bed or furniture may indicate the use of physical restraints

19. Indicators of abuse/neglect (cont.) Physical Abuse (cont.) • Shivering, cyanosis (blue discoloration), flushing, lowered/elevated body temperature • Delays in seeking treatment • Reluctance to give information • History of falls, accidents, injuries for which explanations do not fit the evidence • Seeking medical attention from an excessive number of doctors • Sores, injuries which have not been treated/partially healed • Burns in shapes of objects, such as stove burners or cigarette ends; burns from restraints or bath immersion burn patterns • Bruise on both upper arms, as would result from being grabbed or shaken badly

20. Indicators of abuse/neglect (cont.) Psychological/Emotional Abuse (all forms of abuse and neglect almost always include these indicators.) • Appears shamed • Excessive passivity • Shows fear and inappropriate guilt • Reverts to infant-like/child-like behaviours • Is treated like a child • Seems frightened/eyes dart about, avoids eye/verbal contact with caregiver • Appears nervous in presence of caregiver • Threatened with institutionalization, eviction, etc. • Caregiver speaks for adult with disabilities or senior • Withdrawn, apathetic, depressed • Unresponsive

21. Indicators of abuse/neglect (cont.) Psychological/Emotional Abuse (all forms of abuse and neglect almost always include these indicators.) • Physical indicators of imposed isolation (no telephone or radio, locks on door) • Caregiver blames adult for incontinence or wandering • Caregivers are passive, withdrawn, or uninterested in the person; refers to adult as “it” • Seeks frequent medical attention with vague, unsubstantiated complaints • Excluded from family gatherings, not permitted to have friends visit, to go to church, denied access to children/grandchildren • Unsure, helpless about making decisions • Inappropriate control by others of activities engaged in by at-risk adult

22. Indicators of abuse/neglect (cont.) Sexual Abuse • Pain, bruising and bleeding in the genital area • Existence of sexually transmitted diseases • Pregnancy • Stained, torn or bloody underclothes • Foreign bodies in genital, rectal or urethral openings • Pain, itching in the genital area or throat • Difficulty passing urine or defecating

23. Indicators of abuse/neglect (cont.) Sexual Abuse (cont.) • Semen about the mouth, genitals or on clothing • Enlarged vaginal opening or redness in the genital area • Unusual or offensive odour • Significant change in sexual behaviour or attitude • Excessive masturbation • Simulated sexual acts or sexual attention to pets or animals • Compulsive sexual behaviour (grabbing breasts or genitals or compulsively removing clothes) • Prostitution, or indiscriminate sexual activity

24. Indicators of abuse/neglect (cont.) Financial Abuse and Exploitation • Being overcharged for home repairs, pre-paid funeral arrangements, room and board, etc. • Illegal use of possessions, property, investments for profit, or personal gain • Depletion of savings without owner’s knowledge • Overdrawn/depleted bank account • Discrepancy between standard of living and financial assets • Unusual transactions conducted on behalf of the account holder • Cashing of pension or other cheques/insurance without permission.

25. Indicators of abuse/neglect (cont.) Financial Abuse and Exploitation (cont.) • Disappearance of jewellery, art or other personal possessions • Forced to sign over control/power of attorney • Forced to sell house, change will • Sale or transfer of property by person who seems unsure and confused about reason for selling • Nervous when at the bank with another person, especially if making a large withdrawal • Deliberate financial exploitation (i.e., improper financial compensation)

26. Precipitating factors of abuse/neglect Factors Which May Precipitate Abuse and Neglect in residential facilities - Poor working environment - Inadequate preparation of staff - Lack of opportunity for staff professional/ personal growth - Increasing dependency of resident, extreme impairments - Lack of understanding of aging process, complex health needs of resident - Negative attitude toward aging and/or disabilities. - Insensitivity to needs of individual and families - Lack of positive communication between staff/clients/families

27. Precipitating factors of abuse/neglect (cont). Factors Which May Precipitate Abuse and Neglect in residential facilities - Lack of enforcement of legislation and policies which ensure quality care in institutions • Lack of community resources • lack of awareness of existing community resources - Lack of regular contact with someone other than the primary caregiver - Lack of knowledge regarding how to best work with adults with disabilities and seniors - Lack of common decency - Lack of awareness about how one’s behavior results in the abuse or neglect of others  - Lack of family members or close friends living nearby  - Imbalance of power

28. Violence in residential facilities According to the National Clearinghouse report, seniors living in institutions are particularly vulnerable to abuse due to a lack of institutional resources and difficulties faced by health care workers

29. Violence in residential facilities (cont.) The Ontario College of Nurses surveyed nurses and nurses assistants and found that * 20% reported witnessing abuse of patients in nursing homes; * 31% reported witnessing rough handling of patients; * 28% reported witnessing workers yelling and swearing at patients; * 28% reported witnessing embarrassing comments being said to patients; and * 10% reported witnessing other staff hitting or shoving patients.

30. Violence in residential facilities (cont.) -“Out of Control: Violence against Personal Support Workers in Long Term Care Facilities”, February 2008 Headed by Pat Armstrong of York UniversityFunded by Canadian Institutes of Health Research. This study is based on a survey of workers at 71 unionized long-term care facilities in Manitoba, Ontario, and Nova Scotia. It also draws on front line accounts obtained through focused discussions with long-term care workers.

31. Violence in residential facilities (cont.) This study demonstrates that:  • That workplace violence is an everyday occurrence for many long-term care workers. • Violence is physical, verbal, and sexual. • We also find racism and structural violence – stemming from severe working conditions • Workers believe that they are expected to take such abuse. They are told to "lighten up.” The situation, as one worker put it, is “out of control.”

32. Violence in residential facilities (cont.) • 95.1% of the workers in the study were female • That nearly half (43.0%) of personal support workers are subject to violence every day. The vast majority of violence in long-term care goes unreported • That official reports are generally completed only if medical attention is required • Donna Goodridge and her colleagues estimated that of the 15,000 incidents of violence experienced over a six-month period, less than one per cent (0.27%) had been reported • Residents are entering long-term care older and sicker than they were in the past.

33. Violence in residential facilities (cont.) • It is not unusual to find a long-term care facility with 60 to 70 per cent of its residents suffering from Alzheimer’s disease or other forms of dementia. • Many, if not most residents, also suffer from the burden of multiple diagnoses and impairments. • This places additional stress on caregivers who lack sufficient time and resources to provide proper care.

34. Study Erik Lindbloom, M.D., University of Missouri-Columbia The Role of Forensic Science in Identification of Mistreatment Deaths in Long-Term Care Facilities

35. April 2005 Funded by the National Institute of Justice in conjunction University of Missouri-Columbia

36. Research Goal Identify indicators of abuse or neglect of elderly residents in long-term care facilities

37. Research Objectives • Study the deaths of elderly residents in long-term care facilities to identify potential indicators of abuse or neglect • Examine medical examiner’s reports of elderly nursing home residents in Arkansas over a 1-year period. • Gather information on indicators of mistreatment and identify barriers to accurate assessments of abuse.

38. Research Findings Researchers identified four categories of indicators that often led to further investigation by the Attorney General

39. Research Findings (cont.) 1- Physical condition/quality of care, Indicators included: • Documented but untreated injuries • Undocumented injuries and fractures • Multiple, untreated, and/or undocumented pressure sores • Medical orders not followed • Poor oral care, poor hygiene, and lack of cleanliness of residents • Malnourished residents who have no documentation for low weight • Bruising on non ambulatory residents; • Bruising in unusual locations • Statements from family concerning adequacy of care • Observations about the level of care for residents with non attentive family members

40. Research Findings (cont.) 2 - Facility characteristics, Indicators included: • Unchanged linens • Strong odors (urine, feces) • Trash cans that have not been emptied • Food issues (unclean cafeteria) • Documented problems in the past

41. Research Findings (cont.) 3 - Inconsistencies, Indicators included: • Inconsistencies between the medical records, statements made by staff members, and/or observations of investigators • Inconsistencies in statements among groups interviewed • Inconsistencies between the reported time of death and the condition of the body

42. Research Findings (cont.) 4 - Staff behaviors, Indicators included: • Staff members who followed an investigator too closely • Lack of knowledge and/or concern about a resident • Unintended or purposeful, verbal or nonverbal evasiveness • A facility’s unwillingness to release medical records.

43. Conclusions • This study demonstrated that these indicators were present in the cases of abuse and neglect. • The presence of any one of these indicators may not prove abuse or constitute neglect but should be taken into consideration during investigation.

44. Provincial statistics Year Referrals 2006 433 2007 601 2008 741 2009 850

45. Relationship of trust between client and caregiver/Position of authority Abuse can occur in relationships in which the abuser holds a position of trust and authority over the victim. Being an owner, operator or staff of a residential facility/nursing home, you are automatically in a position of trust and authority over your client. Any type of relationship developed over and above the relationship of caregiver, could become abusive even if the client is consenting. Example: sexual relationship, financial favors, accepting of gifts, etc…..

46. Relationship of trust between client and caregiver/Position of authority (cont.) In institutional settings, some forms of abuse are not always obvious. Subtle emotional harms may occur such as treating older people like children (infantilization) and disregarding their wishes. In some instances, an individual may perpetrate the abuse in environments where the organizational structure fosters power imbalances that perpetuate the situation. This abuse is referred to as “systemic abuse” or “institutional abuse” because the system itself silences the victims (Simmons 2002).

47. Relationship of trust between client and caregiver/Position of authority (cont.) "Systemic abuse" refers to practices that take away a person's independence and dignity. Systemic abuse happens in settings where other people are making decisions for the person who has a disability. Government bodies and bureaucrats can also be involved in systemic abuse. In facilities, every day practices ("the way things are done here") and lack of sensitivity may create abusive or neglectful situations for older adults. Systemic forms of abuse or neglect may occur in these settings (e.g., "routine use" of incontinence briefs instead of helping the senior to the washroom because the facility does not have enough staff, or for staff convenience).

48. Relationship of trust between client and caregiver/Position of authority (cont.) In some institutional settings, systemic neglect may occur where there is not sufficient number of staff to meet the residents’ needs. There are other types of abuse or neglect that may occur in institutions, such as • abuse by over-medication or under medication • abuse by inappropriate use of physical or chemical (medication) restraints

49. Relationship of trust between client and caregiver/Position of authority (cont.) - thefts of residents' personal property because of lack of security Some forms of institutional abuse violate people's rights to accept or decline treatment. Some examples may include requiring that all seniors sign advance directives before being admitted to a long term care facility; placing a "do not resuscitate" order on medical records without consulting with the senior or family, and overriding a mentally capable senior’s personal health decisions.

50. Relationship of trust between client and caregiver/Position of authority (cont.) People with special needs, including people with physical or developmental disabilities and older adults living in attendant care facilities, are particularly vulnerable to systemic abuse. One study, for example, showed that the more women with disabilities depend on professional caregivers for assistance with personal daily living tasks, the more susceptible they became to both physical and psychological abuse (Curry, Hassouneh-Phillips and Johnston-Silverberg 2001, 70-71).