Abuse, Neglect, and Exploitation (ANE) Module


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Abuse, Neglect, and Exploitation (ANE) Module

Abuse, Neglect, and Exploitation

May 2017

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Table of Contents
About this Module/Overview/Objectives……………………………………………...Page 3 Pre-test………………………………………………………………………………..Pages 4-5 Chapter 1……………………………………………………………………………...Pages 6-8
Overview Definitions Categories of Abuse State Reporting and Investigation Requirements/Safe Harbor and ANE
Chapter 2……………………………………………………………………………...Pages 9-11 Signs and Symptoms Risk Factors Factors in Nursing Homes Assessment/Screening/Identification of ANE
Chapter 3……………………………………………………………...………………Pages 12-13 Personal-Accountability Prevention of ANE
Chapter 4…………………………………………………………………………….Pages 14-16 Federal Regulation
Chapter 5………………………………………………………………………….......Pages 17-21 Resources Videos Examples Case Scenario Activities Scavenger Hunt ANE In-service Presentation CMS Hand-in-Hand Modules 2 & 5
Post-test………………………………………………………………………………Pages 22-23

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About this Module:
Nurses must be able to recognize the clinical indicators of elder abuse, neglect, and exploitation (ANE) and need to know what actions to take if ANE is suspected. However, many nurses are not aware that ANE even exists, and few are adequately trained to screen and assess for ANE. Understanding cultural competency is essential to any ANE training. Different cultures perceive aging and care-giving differently and this has important implications for the way ANE is viewed, assessed and treated. Elder ANE are universal problems, and are highly prevalent in institutional type settings such as nursing homes. Raising awareness and prevention of elder ANE requires the involvement of the nurse providing care to these individuals. To assist in raising awareness, the ANE Module of this toolkit was developed.
Overview:
Every year, an estimated 4 million older Americans are victims of physical, psychological or other forms of abuse and neglect. Those statistics may not tell the whole story. For every case of elder abuse and neglect reported to authorities, experts estimate as many as 23 million cases go undetected. The quality of life of older individuals who experience abuse is severely jeopardized; they often experience worsened functional and financial status, as well as progressive dependency, poor self-rated health, feelings of helplessness and loneliness and increased psychological distress. Research also suggests that older people who have been abused tend to die earlier than those who have not been abused, even in the absence of chronic conditions or life-threatening disease. Like other forms of abuse, elder abuse is a complex problem, and it is easy for people to have misconceptions about it.
Effective interventions can prevent or stop elder abuse. Improving the ANE training of nurses who provide care to older adults in nursing facilities can help break patterns of abuse or neglect, and both the person experiencing the abuse and the abuser can receive needed help.
Objectives:
The objectives for this module are:
a. Identify the signs and symptoms of ANE
b. Describe factors contributing to institutional ANE of elders
c. Discuss the available resources for reporting elder ANE and obtaining assistance
d. Describe the nurse’s role in identification and prevention of elder ANE
e. Discuss Federal and State Regulations

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Pretest:

1. Physical abuse is the most common form of abuse that is inflicted on elder individuals.

True

False

2. Sexual abuse is only diagnosed when the resident describes rape.

True

False

3. Neglect is a lesser form of mistreatment against elders.

True

False

4. Elder mistreatment is a public health problem.

True

False

5. The number of new cases of elder mistreatment reported in the United States each year is almost 500,000 and represent a major public health problem.

True

False

6. Bruises over the chest and face are indicators of physical abuse.

True

False

7. Malnutrition is always an indicator of neglect.

True

False

8. Hip fractures are not indicators of elder abuse in residents older than 75 years because these residents usually have osteoporosis and a history of frequent falls.

True

False

9. A red-purple bruise is more severe and older that a yellow-green one.

True

False

10. Skin lacerations are cuts with raised, inflamed edges.

True

False

11. Decubiti are normal lesions of the skin in residents who cannot move without help.

True

False

12. Residents who are unable to perform 4 activities of daily living (ADLs) are at less risk of ANE than residents who are isolated.

True

False

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13. Dehydration is a common presenting sign of neglect and can be complicated by confusion.

True

False

14. Those that are isolated are more vulnerable to an instance of ANE.

True

False

15. Burns are common injuries in elders who live in nursing homes.

True

False

16. Elders are never victims of sexual abuse.

True

False

17. Only social workers are responsible for the assessment of elder mistreatment.

True

False

18. Excessive or insufficient medication of an older patient is an indicator of ANE.

True

False

19. An incidence of ANE that is reported by a resident with dementia should be investigated by the care provider.

True

False

20. Alcoholism is a risk factor of ANE only if the care provider is a heavy drinker.

True

False

Answers: 1. F 5. T 9. F 13. T 17. F

2. F 6. T 10. T 14. T 18. T

3. F 7. F 11. F 15. F 19. T

4. T 8. F 12. F 16. F 20. T

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Chapter 1:
Overview:
Abuse, neglect and exploitation are some of the worst experiences an older adult might go through in their life. It is estimated that 1 in 4 vulnerable elders are at risk for abuse1, with estimated occurrences of abuse in 1 out of every 3 nursing homes2. Since April of 2012, the instances of verified ANE complaints in Texas NFs have been increasing, from 645 cases between April 1, 2012 and March 31, 2013 to 1023 cases from April 1, 2014 through March 31, 2015. According to the National Center on Elder Abuse, the number of older adults who are mistreated each year is close to 5 million and is rising3. The instance of ANE to a NF resident can impact his or her physical, mental, and emotional well-being, and can lead to death.
As adults grow older they may become more physically frail, may not see or hear as well as they used to, and may develop cognitive problems such as dementia. As a result, they become increasingly vulnerable to abuse and neglect. Elder abuse laws have been enacted in each individual state, and the Centers for Medicare & Medicaid Services has issued regulations for nursing facilities as well. As caregivers it is your responsibility to know both your state and federal regulations.
We know the mistreatment of older adults takes many forms, including physical, verbal, emotional and sexual abuse, financial exploitation, and neglect. This is the case even though incidents of abuse often go unreported. Why aren’t they reported? Victims of elder abuse and neglect may feel ashamed of their abusive experiences. Those who consider reporting abuse often choose not to because, in the majority of cases, they are abused by a family member, loved one, or trusted caregiver.
Definitions:
a. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish (42 CFR §488.301)4. Abuse can be mental, physical, sexual, or verbal. According to Federal Regulations Tag 223, the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion caretaker, family member, or other individual who has an ongoing relationship with the person5.
b. Neglect: The refusal or failure to provide good or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness4. Neglect typically

1 Oxford Journals. The prevalence of elder abuse and neglect: a systematic review. http://ageing.oxfordjournals.org/content/37/2/151.long 2 ABC News. Elderly Abused at 1 in 3 Nursing Homes: Report. http://abcnews.go.com/US/story?id=92689 3 HealthinAging.org. Resources: Preventing Elder Abuse and Neglect in Older Adults. http://www.healthinaging.org/resources/resource:preventing-elder-abuse-and-neglect-in-older-adults/ 4 Code of Federal Regulations (2016). Retrieved from http://www.ecfr.gov/cgi-bin/ECFR?page=browse 5 Texas Administrative Code, Title 40, Part 1, Chapter 19, Subchapter B, Rule §19.101 Definitions. http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=4 0&pt=1&ch=19&rl=101

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means the refusal or failure of those responsible to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials. c. Exploitation: the illegal or improper use of an elder's funds, property, or assets. Examples include, but are not limited to, cashing an elderly person's checks without authorization or permission; forging an older person's signature; misusing or stealing an older person's money or possessions; coercing or deceiving an older person into signing any document (e.g., contracts or will); and the improper use of conservatorship, guardianship, or power of attorney6.
Categories of Abuse:
a. Physical Abuse: The use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. In addition, inappropriate use of drugs and physical restraints, force feeding, and physical punishment of any kind are examples of physical abuse5.
b. Emotional or Psychological Abuse: The infliction of anguish, pain, or distress through verbal or nonverbal acts. Emotional/psychological abuse includes but is not limited to verbal assaults, insults, threats, intimidation, humiliation, and harassment. In addition, treating an older adult like an infant, isolating the individual, giving the individual the “silent treatment”, and enforced social isolation are examples of emotional/psychological abuse5.
c. Sexual Abuse: Non-consensual sexual contact of any kind with an elderly person. Sexual contact with any person incapable of giving consent is also considered sexual abuse. It includes, but is not limited to, unwanted touching, all types of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photographing5.
State Reporting and Investigation Requirements/Safe Harbor and ANE:
Reporting an instance of ANE in a Nursing Facility is required by both the Texas nursing facility licensing regulations and the Texas Board of Nursing Rules and Regulations. Texas Administrative Code (TAC) Title 40, Part 1, Chapter 19, Subchapters G and T, Rule §19.602 and Rule 19.1923 detail that nursing facility owners or employees must report any suspected incidents of ANE to the Texas Department of Aging and Disability Services (DADS) at 1-800458-9858 or by mail at DADS Consumer Rights and Services, P.O. Box 14930, Austin, Texas 78714-9030 and Law Enforcement Agencies as necessary. The requirement is that the report must first be made by phone immediately on learning of any instance of abuse, with the written report sent within five days after the telephone report. Upon reporting the instance, the facility is

6 National Center of Elder Abuse Administration on Aging. Types of Abuse. http://www.ncea.aoa.gov/FAQ/Type_Abuse/index.aspx#sexual

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required to also conduct an investigation of the reported instance no later than the fifth working day after the verbal report of the incident78.
Texas Administrative Code (TAC) Title 22, Part 11, Chapter 217, Rule §217.11 as well as Section 301.402 of the Nursing Practice Act9 detail a nurse’s required compliance with the mandatory reporting requirements of the Nursing Practice Act in Texas Occupations Code Chapter 301, Subchapter I. This rule requires that a nurse must report any nurse whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries10.
If you become suspicious of, witness, or are told of an instance of ANE being perpetrated against a resident, you are responsible for ensuring the safety of the individual until the proper authorities investigate. It is a requirement of state law, as previously mentioned that the healthcare entity performs an investigation of the any report of ANE. The LVN may not be directly responsible for interviewing the individual; however, he/she may be called upon during the investigation to provide any information related to the case.
The federal regulations also require nursing facilities to report alleged violations that involve abuse, neglect, exploitation or mistreatment including injuries of unknown sources and misappropriation of resident’s property. These violations must be reported immediately or within 2 hours after the allegation is made.

7 TAC Title 40, Part 1, Chapter 19, Subchapter G, Rule §19.602. http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=4 0&pt=1&ch=19&rl=602 8 TAC Title 40, Part 1, Chapter 19, Subchapter T, Rule §19.1923. http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=4 0&pt=1&ch=19&rl=1923 9 Nursing Practice Act, Nursing Peer Review, & Nurse Licensure Compact Texas Occupations Code and Statutes Regulating the Practice of Nursing. http://www.bon.texas.gov/laws_and_rules_nursing_practice_act_2013.asp#Sec.301.402 10 TAC Title 22, Part 11, Chapter 217, Rule §217.11. http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=2 2&pt=11&ch=217&rl=11

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Chapter 2:
Signs and Symptoms:
Perhaps the most difficult aspect of recognizing the signs and symptoms of ANE is that some of these are the same as those of normal aging process. Therefore, it is very important to recognize changes in behavior or health as potential indicators of ANE. In recognizing the signs and symptoms, it is important to differentiate ANE from normal signs of aging.
Signs and symptoms of ANE include but are not limited to (all of these could be normal signs of aging as well and should be further investigated):
1. Physical abuse: a. Bruises, black eyes, welts, lacerations, and rope marks; b. Bone fractures, broken bones, and skull fractures; c. Open wounds, cuts, punctures, untreated injuries in various stages of healing; d. Sprains, dislocations, and internal injuries/bleeding; e. Broken eyeglasses/frames, physical signs of being subjected to punishment, and signs of being restrained; f. Laboratory findings of medication overdose or underutilization of prescribed drugs; g. An individual’s report of being hit, slapped, kicked, or mistreated; h. An individual’s sudden change in behavior; i. The caregiver’s refusal to allow visitors to see an individual alone; or j. Burns.

2. Emotional/Psychological Abuse: a. Being emotionally upset or agitated; b. Being extremely withdrawn and non-communicative or non-responsive; c. Unusual behavior usually attributed to dementia; or d. An individual’s report of being verbally or emotionally mistreated

3. Sexual Abuse: a. Bruises around the breasts or genital area; b. Unexplained venereal disease or genital infection; c. Unexplained vaginal or anal bleeding; d. Torn, stained, or bloody underclothing; and e. An individual’s report of being sexually assaulted or raped.

4. Neglect: a. Dehydration, malnutrition, untreated bed sores, and poor personal hygiene; b. Unattended or untreated health problems; c. Unsanitary conditions (dirty, lice on the person, soiled bedding, fecal/urine smell); and

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d. An individual’s report of being neglected.
5. Exploitation: a. Abrupt changes in a will or other financial documents; b. Unexplained disappearance of funds or valuable possessions; c. Discovery of an individual’s signature being forged for financial transactions or for the titles of his/her possessions; and d. An individual’s report of financial exploitation5.
Risk Factors of Perpetrating ANE:
A combination of individual, relational, community and societal factors contribute to the risk of someone becoming a perpetrator of elder ANE. The responsibilities and demands of elder caregiving, which escalate as the elder’s condition deteriorates, can be extremely stressful. The stress of elder care can lead to mental and physical health problems that cause nursing staff to become burned out, impatient, and unable to keep from lashing out against their elderly residents. Nursing home staff may be prone to abusing their elderly residents if they:
a. Lack training; b. Have too many responsibilities; c. Are unsuited to caregiving; d. Are unable to cope with stress (lack of resilience); e. Are depressed; f. Have a history of/currently abuse substances; or g. Work under poor conditions.
In many cases, elder ANE, though real, is unintentional. Nursing staff who are pushed beyond their capabilities or psychological resources may not mean to yell at, strike, or ignore the needs of their residents.
Risk Factors for Becoming a Victim of ANE11:
Several factors concerning the residents themselves can influence whether or not they are at greater risk for abuse. These risk factors include (but are not limited to):
a. Gender: women are more likely than men to be victims of ANE b. Age: older adults are at higher risk, with the average age being older than 78 c. Functional capacity: those individuals who are immobile or have significant decline in their
physical functioning are often at a higher risk of being victims because of their dependency on others.

11 World Health Organization (WHO). Chapter 5: Abuse of the elderly. http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap5.pdf

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Abuse, Neglect, and Exploitation (ANE) Module