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MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 1 Managing and Preventing Reducing Elder Abuse in Residential Long-Term Care Facilities Hamed Ishola Name of Student Professor Sharmi Mahajan Presented to the Faculty of the Health Law/Compliance and Enterprise Risk Management Program, Loyola University Chicago School of Law in Partial Fulfillment of the Requirements for the Degree of Master of Jurisprudence (M.J.). Fall 2023

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 2 Contents Executive Summary ................................................................................................................................... 3 1.1 Introduction ......................................................................................................................................... 4 Literature Review ...................................................................................................................................... 4 Problem Statement .................................................................................................................................. 10 Capstone Statement ............................................................................................................................. 10 Project Goals and Objectives .............................................................................................................. 10 Target Audience ................................................................................................................................... 10 Project Deliverables ............................................................................................................................. 12 Project Overview ..................................................................................................................................... 12 Project Methodology ........................................................................................................................... 12 Assessment and Conclusion .................................................................................................................... 16 Summary of findings ........................................................................................................................... 16 Summary of additional research or resources needed: ..................................................................... 19 Assessment of project outcomes .......................................................................................................... 72 Suggestions for next steps or improvements ...................................................................................... 72 Conclusion ............................................................................................................................................ 72

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 4 and tracking elder abuse cases, expediting detection and management. The system will ensure the efficiency of addressing such incidents while providing timely support and intervention. Managing and Preventing Elder Abuse in Residential Long-Term Care Facilities 1.1 Introduction E The issue of e lder abuse in long-term care (LTC) residential care facilities seriously jeopardizes the dignity and well-being of older people in society. By nature of their state, older people who receive care from such facilities are vulnerable to abuse. Such vulnerability results from physical frailty, cognitive decline, reliance on other people for daily duties, and a lack of a solid social support system (Wang & Mears, 2010). . Different factors can also account for allow elder abuse to continue in these institutions. Such These include understaffing, inadequate understanding of legal and regulatory responsibilitiesy, inadequate responsibilities inadequate training, poor monitoring, and insufficient monitoring and oversight procedures (Wang & Mears, 2010). . The abuse of older people has its repercussions. These include mental anguish, bodily pain, diminishing health, and higher mortality rates, which can lead to consequences such as, not limited to, civil lawsuits, criminal charges, regulatory investigations and penalties, wrongful death lawsuits, and class-action lawsuits 2 . It is, therefore, essential to ensure that the issue of elder abuse is properly addressed to the residents and employees as well providing all preventive methods to curb the problem. addressed through preventive methods that are management- focused and proactive. 2 https://www.nursinghomeabuse.org/nursing-home-neglect/#:~:text=Failing%20to%20provide%20proper%20care,from%20law %20enforcement%20or%20lawsuits

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 5 Literature Review Elder abuse in long-term residential facilities is a distressing problem that requires attention due to patient safety and dignity concerns, and potential non - compliance with regulations 3 . Older people must be assured of security and dignity as they grow. Studies have consistently shown that elder abuse is common in such facilities. A survey conducted by Yon et al. (2019) 4 showed that the prevalence estimates for abuse subtypes were highest for psychological abuse at 33.4%, followed by physical abuse at 14.1%, followed by financial abuse at 13.8%, and lastly, sexual abuse at 1.9%. In another study, 54.7% of the care workers had observed abuse in their daily practice in the preceding 12 months (Gil & Capelas, 2022) 5 . The consequences of elder abuse on the victims are dire, which lead to physical injuries, psychological distress, increased mortality rates, and reduced quality of life (Johnson & Fertel, 2020) 6 . Various factors account for elder abuse. One is staffing issues such as high turnover rates and inadequate training (Botngard et al., 2020) 7 . Also, the challenging nature of caregiving for this age group can lead to burnout of the caregivers, which increases the likelihood of abuse (Ostaszkiewicz, 2018) 8 . The lack of knowledge and awareness regarding elder abuse and its prevention is also a factor (Myhre et al., 2020). Regulations and guidelines are crucial in establishing the framework for preventing elder abuse. The CODE OF FEDERAL REGULATIONS, TITLE 42, SECTION 483.12, outlines the steps the facilities must take to ensure freedom from abuse, neglect, and resident exploitation (Carlson, 2010) 9 . State-specific laws, regulations , and policies also further support the prevention efforts 3 Wang, K. K., & Mears, J. (2010). The national legal framework for the prevention of elder abuse in the United States. Aging & Mental Health, 14(5), 578-586. 4 Yon, Y., Ramiro-Gonzalez, M., Mikton, C. R., Huber, M., & Sethi, D. (2019). The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis. European Journal of Public Health, 29(1), 58-67. https://doi.org/10.1093/eurpub/cky093 5 Gil, A. P., & Capelas, M. L. (2022). Elder abuse and neglect in nursing homes as a reciprocal process: the view from the perspective of care workers. The Journal of Adult Protection, 24(1), 22-42. https://doi.org/10.1108/JAP-06-2021-0021 6 Johnson, M. J., & Fertel, H. (2020). Elder abuse. StatPearls Publishing. 7 Botngård, A., Eide, A. H., Mosqueda, L., & Malmedal, W. (2020). Elder abuse in Norwegian nursing homes: a cross-sectional exploratory study. BMC Health Services Research, 20(1), 1-12. https://doi.org/10.1186/s12913-019-4861-z 8 Myhre, J., Saga, S., Malmedal, W., Ostaszkiewicz, J., & Nakrem, S. (2020). Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders’ perceptions of elder abuse and neglect. BMC Health Services Research, 20(1), 1-14. https://doi.org/10.1186%2Fs12913-020-5047-4 9 Carlson, E. M. (2015). 20 Common Nursing Home Problems--and how to Resolve Them. Washington: National Senior Citizens Law Center. https://www.agingresources.com/wp-content/uploads/2016/12/20CommonNurseHomeProblems-1.pdf (Accessed: 31 July 2023)

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 7 Promising practices have been identified to prevent and manage elder abuse for the long-term. Creating an organizational culture that prioritizes resident safety and well-being is essential (Kaspiew et al., 2019) 16 . Training programs for employees covering that recognize signs of abuse, reporting procedures, and effective interventions are crucial (Nyarko, 2022) 17 . Additionally, establishing reporting and monitoring mechanisms that are clear, coupled with immediate action on incidents that are being reported, is essential (Ferreira & Lindgren, 2008) 18 . Incentivization of the process can also help (Yunus, 2021) 19 . Several case studies have demonstrated successful interventions such as interdisciplinary collaboration and community engagement to prevent and manage elder abuse in these long-term facilities. One case study showed that such intervention programs s had a role to play in reducing depression and burnout of caregivers, which would, in turn, minimize elder abuse because of caregiver mental health challenges (Baker et al., 2016) 20 . Another study highlighted the role of interdisciplinary collaboration and community engagement in developing effective elder abuse prevention programs (Dong, 2015) 21 . While promising practices and successful interventions exist, challenges and barriers still exist remain to prevent elder abuse in long-term care facilities. Insufficient resources and funding can hinder the implementation of comprehensive abuse prevention programs (Dong et al., 2014) 22 . 16 Kaspiew, R., Carson, R., Dow, B., Qu, L., Hand, K., Roopani, D., Gahan, L., & O'Keeffe, D. (2019). Elder abuse national research- strengthening the evidence base: research definition background paper. Melbourne: Australian Institute of Family Studies. https://aifs.gov.au/sites/default/files/publication-documents/1908_elder_abuse_national_research_strengthening_the_evidence_base.pdf (Accessed: 31 July 2023) 17 Nyarko, V. K. (2022). Abuse of the elderly in nursing homes: a scoping review [Bachelor’s thesis, Novia University of Applied Sciences]. 18 Ferreira, M., & Lindgren, P. (2008). Elder abuse and neglect in South Africa: A case of marginalization, disrespect, exploitation and violence. Journal of Elder Abuse & Neglect, 20(2), 91-107. https://doi.org/10.1080/08946560801974497 19 Yunus, R. M. (2021). Researching institutional elder abuse in Malaysia: challenges and recommendations. Gerontology, 67(4), 449-452. https://doi.org/10.1159/000513932 20 Baker, P. R., Francis, D. P., Hairi, N. N., Othman, S., & Choo, W. Y. (2016). Interventions for preventing abuse in the elderly. Cochrane Database of Systematic Reviews, 2016(8), CD010321. https://doi.org/10.1002%2F14651858.CD010321.pub 2 21 Dong, X. Q. (2015). Elder abuse: Systematic review and implications for practice. Journal of the American Geriatrics Society, 63(6), 1214- 1238. https://doi.org/10.1111/jgs.13454 22 Dong, X., Chen, R., & Simon, M. A. (2014). Elder abuse and dementia: a review of the research and health policy. Health Affairs (Project Hope), 33(4), 642-649. https://doi.org/10.1377/hlthaff.2013.1261

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 8 Staff resistance to change and reluctance to report incidents due to fear of repercussions may impede effective interventions (Teresi et al., 2013) 23 . Dong et al. (2014) identify some of the issues associated with low resources and financing in their review of the research on elder abuse prevention. These budgetary restraints can potentially slow the deployment of comprehensive abuse prevention initiatives. Training for the personnel, expanded monitoring systems, and more support services for the residents are all examples of possible components of such programs. Researchers Teresi and colleagues (2013) also shed light on worker resistance to change and hesitation to disclose instances due to worries about penalties. Because of this reluctance, effective therapies are far more challenging to implement . To successfully overcome these obstacles, a multi-pronged approach is required, combining regulatory measures with methods designed to address the organizational culture within long- term care institutions. Ethical Considerations Ethical considerations are paramount in preventing elder abuse. A resident-centered approach, emphasizing resident autonomy and empowerment, is critical in abuse prevention efforts (Grubman, 2015) 24 . Supporting residents' ability to communicate concerns and preferences is essential to maintaining their safety and dignity (Schiamberg et al., 2012) 25 . In the context of preventing abuse of old people in long-term care facilities, several laws rules and regulations have been enacted , and regulations promulgated, to preserve the residents' health and protect their legal rights. The regulatory environment has undergone significant change over 23 Teresi, J. A., Ramirez, M., Ellis, J., Silver, S., Boratgis, G., Kong, J., Eimicke, J. P., Pillemer, K., & Lachs, M. S. (2013). A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial. International Journal of Nursing Studies, 50(5), 644-656. https://doi.org/10.1016/j.ijnurstu.2012.10.010 24 Grubman, J. F. (2015). Methods for managing risk and promoting resident-centered care in nursing homes. Columbia Journal of Law and Social Problems, 49(2), 217-249. https://jlsp.law.columbia.edu/wp-content/blogs.dir/213/files/2017/03/49-Grubman.pdf 25 Schiamberg, L. B., Oehmke, J., Zhang, Z., Barboza, G. E., Griffore, R. J., Von Heydrich, L., Post, L. A., Weatherill, R. P., & Mastin, T. (2012). Physical abuse of older adults in nursing homes: a random sample survey of adults with an elderly family member in a nursing home. Journal of Elder Abuse & Neglect, 24(1), 65-83. https://doi.org/10.1080/08946566.2011.608056

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 10 potentially slow the deployment of comprehensive abuse prevention initiatives. Training for the personnel , expanded monitoring systems, and more support services for the residents are all examples of possible components of such programs. Researchers Teresi and colleagues (2013) also shed light on worker resistance to change and hesitation to disclose instances due to worries about penalties. Because of this reluctance, effective therapies are far more challenging to implement 32 . To successfully overcome these obstacles, a multi-pronged approach is required, combining regulatory measures with methods designed to address the organizational culture within long-term care institutions. According to Grubman (2015), the consideration of ethical issues plays a significant part in preventing abuse of elderly people; it is essential to have a stance that centers on the needs of the residents and emphasizes their autonomy and sense of agency 33 . This strategy is in line with supporting the residents' ability to communicate concerns and preferences, which are crucial factors in protecting the residents' safety and dignity 34 . In long-term care facilities, a culture of respect and care can be fostered with the help of an emphasis on ethical behaviors, which not only helps long-term care facilities comply with legal requirements but also contributes to the development of such a culture 35 . 32 Teresi, J. A., Ramirez, M., Ellis, J., Silver, S., Boratgis, G., Kong, J., Eimicke, J. P., Pillemer, K., & Lachs, M. S. (2013). A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial. International Journal of Nursing Studies, 50(5), 644-656. https://doi.org/10.1016/j.ijnurstu.2012.10.010 33 Grubman, J. F. (2015). Methods for managing risk and promoting resident-centered care in nursing homes. Columbia Journal of Law and Social Problems, 49(2), 217-249. https://jlsp.law.columbia.edu/wp-content/blogs.dir/213/files/2017/03/49-Grubman.pdf 34 Schiamberg, L. B., Oehmke, J., Zhang, Z., Barboza, G. E., Griffore, R. J., Von Heydrich, L., Post, L. A., Weatherill, R. P., & Mastin, T. (2012). Physical abuse of older adults in nursing homes: a random sample survey of adults with an elderly family member in a nursing home. Journal of Elder Abuse & Neglect, 24(1), 65-83. https://doi.org/10.1080/08946566.2011.608056 35 Kusmaul, N., Bern-Klug, M. & Bonifas, R. Ethical Issues in Long-term Care: A Human Rights Perspective. J. Hum. Rights Soc. Work 2 , 86– 97 (2017). https://doi.org/10.1007/s41134-017-0035-2

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 11 Problem Statement Capstone Statement The implementation of a comprehensive plan that will prevent or limit the abuse of the elderly in long-term residential places is paramount. This is because some of the abuse victims will not report such incidents. By creating a proactive approach, the dignity and well-being of the elderly will be safeguarded. And it will foster an environment of trust and support. Project Goals and Objectives The primary goal of this project is to prevent abuse in long-term residential environments for the elderly. A reduction in the reported incidents of elderly abuse will measure the success of this project. My objectives include implementing creating/revising educational materials, training programs, reporting and response protocols, provision of resident and family support, and establishment of efficient monitoring and evaluation processes for the program's effectiveness. Target Audience The impact of the project will extend to various stakeholders. These include staff and caregivers, residents, families, facility management, regulatory agencies, and community organizations. Through the involvement of such a diverse group, a collaborative effort can be created to protect the elderly from abuse. 1) Staff Members and Caregivers: In long-term residential homes, the staff members and caregivers are the ones who are at the forefront of providing care for residents 36 . Their involvement in the study reflects a dedication to enhancing the care level provided to the elderly. Through participation in training programs and increased 36 Types of Nursing Home Employees - Nursing Home abuse . Types of Nursing Home Employees Comments. (n.d.). https://www.nursinghomeabuseguide.org/resources/types-of-employees

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 13 ensure that management at the institution will continue to be responsive to the shifting requirements of residents and the challenges of preventing elder abuse. Regulatory agencies: Besides functioning as a primary law enforcement agency, they play an essential role for multiple reasons 41 . They oversee the development and enforcement of the rules and regulations that regulate the operations of long-term care facilities 42 . Individual participation ensures that these establishments follow the established protocols to reduce elder abuse. Participation in the program allows regulatory bodies to improve oversight systems by fostering close collaboration with institutions to develop and implement rules and procedures to protect residents in long-term care facilities. Furthermore, regulatory agencies have the authority to develop and update regulations to avoid and reduce elder abuse 43 . Further, the collaborative involvement of regulatory agencies, which can contribute to the formulation and execution of comprehensive programs, can strengthen education and training activities. These programs can target facility employees, caregivers, and management people, enhancing their understanding of elder abuse prevention policies. Community Organizations: They play a significant part in the anti-elder abuse movement, a priority for the United States 44 . Because of their cooperation, the scope of the project's influence is expanded beyond the confines of individual facilities. Working in conjunction with local groups enables the dissemination of information to a broader 41 42 USCS § 3058i 42 320 ILCS 20/3.6 43 320 ILCS 20/3.6 44 Elder abuse prevention . ACL Administration for Community Living. (n.d.). https://acl.gov/programs/protecting-rights-and-preventing- abuse/elder-justice

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 14 audience regarding the prevention of abuse of elderly people. This involvement fosters a sense of social responsibility within the community, increasing the reporting and monitoring of instances of elder abuse. Project Deliverables Several deliverables must be provided to achieve the goals and reach the target audience. One is developing and distributing educational materials to raise awareness of elder abuse. Also, training programs will be designed to equip staff and caregivers with the necessary knowledge and skills. Reporting and response protocols will be established to ensure swift action during abuse incidents. Support to residents and families will also be offered to address their concerns. In conclusion Finally , it is imperative to establish a comprehensive monitoring and evaluation framework to evaluate the program's effects and implement essential enhancements to ensure its sustained efficacy. Abuse, Neglect, Exploitation , and Misappropriation of Property Training: https://www.youtube.com/watch?v=gUy0QbMaNG8

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 16 exploitation as defined in this subpart (42 CFR § 483.12) 45 . I will pass out an abuse in-service questionnaire so that I can get an understanding of the type of knowledge that the trainees have so far. In-Service Training Questionnaire Title: Understanding and Identifying Abuse in Long-Term Care Settings Name (Optional): __________________________________________ Position/Role: _____________________________________________ 1. Background Information:  Have you previously worked in the long-term care sector? Circle yes or no.  Yes  No 2. Definition of Abuse:  In your own words, how would you define "abuse"? __________________________________________________________________ __________________________________________________________________ ____________ 3. Identifying Abuse: 45 Legal Information Institute. (n.d.). 42 CFR § 483.12 - freedom from abuse, neglect, and exploitation. Legal Information Institute. https://www.law.cornell.edu/cfr/text/42/483.12

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 17  How can one identify signs of abuse in a long-term care setting? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________ 4. Have you ever witnessed abuse, Yes or No? If yes, what did you do? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 5. Resident Rights:  According to 42 CFR § 483.12, residents have the right to be free from certain types of abuse. Can you list at least three of these abuses? __________________, _________________, and _____________________________. 6. List the seven types of abuse. i. ______________________________ ii. ______________________________ iii. ______________________________ iv. ______________________________ v. ______________________________ vi. ______________________________ vii. ______________________________ Training Subjects and Resources:

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 19 8. Self-Care for Caregivers: Addressing the emotional toll of handling abuse cases and supplying participants with self-care techniques such as counseling and so on. 9. Role-Playing Scenarios: Conduct interactive drills to simulate real-life situations and practice suitable answers. 10. Assessment and Documentation: Instruction on accurately assessing a situation, recording results, and keeping up-to-date records. Seven Types of Abuse (Bernstein, J. G.) 46 46 Bernstein, J. G. (2023, August 22). 7 common types of nursing home abuse: Bernstein injury law. Jack Bernstein, Injury Attorneys. https://bernsteininjurylaw.com/blog/7-common-types-nursing-home-abuse/

MANAGING AND PREVENTING ELDER ABUSE in RESIDENTIAL LONG-TERM in CARE FACILITIES 20 Abuse Types Definition Signs Prevention & Possible Intervention Neglect Nursing home neglect is characterized by the failure of a caregiver to deliver a sufficient standard of care that adequately addresses the requirements of a patient in a nursing home setting.  Insufficient provision of medical care  Failure to offer sufficient sustenance in the form of food and drink  Presence of an insufficient number of staff members. It is important for advocates and family members to monitor any changes in their loved one's condition or course of therapy. It is important to treat neglect seriously since it can have detrimental effects on a victim's physical and mental health. Emotional Abuse Elder emotional abuse frequently goes unreported. Abuse of this kind involves actions taken against a resident of a nursing home with the  Unusual withdrawal  Modifications to regular demeanor or conduct  Reluctance to discuss the problem Family members and loved ones must constantly watch how their elderly loved ones are interacting with caregivers and other facility staff in order