Abuse, neglect and fraud in the PCH setting

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The US government regulation state that one of the rights a resident in a facility is to be free from physical, verbal, sexual, mental abuse, corporal punishment and involuntary seclusion. The residents that reside in a facility are protected by local, state and federal laws including those that prohibit assault and battery or sexual abuse. Physical abuse is willful infliction of harm or force through physical action that can result in bodily injury, physical pain or impairment. Self-neglect is a person’s refusal or failure to provide him or herself with adequate food, water, clothing, personal hygiene, medications and safe precautions.Verbal abuse is defined as any oral written or gestured communications that is disparaging, derogatory or humiliating and could offend or hurt the resident’s feelings. Emotional or psychological abuse is the infliction of anguish, pain, or distress through verbal or nonverbal acts. Financial abuse is the illegal or improper use of a resident’s funds, property or assets. Abandonment is the desertion of a resident by an individual who has assumed responsibility for providing care for the resident or by a person with physical custody such as a PCH facility. Negligence the refusal or failure to provide the appropriate care required to increase the safety and health status of the resident while under the care of the facility.

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Unintentional abuse most times occurs when the caregiver or staff are overworked, tired and frustrated with the repeated requests or needs of the resident. This type of abuse occurs most often during care or with the provision of needed services, such as shoving a spoon of food into a residents mouth with force that can injure the mouth or throat, pulling a resident’s hair during care and combing because the resident will not sit still or cooperate. The resident is repeatedly incontinent and does not ask to be toileted, the caregiver delays care and changing that ultimately results in breakdown of skin integrity and embarrassment on the part of the resident.

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Neglect can also occur unintentionally with lack of time and too large a case load on the staff so that all the required personal hygiene is not performed daily, leaving the residents in dirty clothing, smelling of body odor or bodily excretions and encouraging skin breakdown and discomfort as well as physical injury. The lack of provisions of medical care can result in worsening medical status or delay in health improvement or stabilization.

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The essential key to providing optimal care for the residents of the PCH facility is education of the staff in the needs of the residents and the proper methods for care of the frail elderly and those with special needs. Education in feeding techniques, ambulation safety and mobility safety are essential as well as the necessity for adequate skin care and nutrition to provide the residents with the needed elements for quality of life and personal safety.

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Abuse and neglect go unnoticed due to the fact that the frail elderly and those with special needs fear retaliation by their caregiver and further withholding of needed care or punishment resulting in withholding of freedoms and privileges.

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Chemical restraints that include sedatives, CNS depressants and relaxants constitute the use of physical abuse because they all can inhibit the freedom of the resident to move about freely and to leave the residence without assistance. The use of medications can also be considered a restraint that qualifies for unlawful confinement against ones will. Withholding privileges where the caregiver provides access to or has in their possession the personal property of the resident and the unlawful consumption of a resident’s private foods or snacks is a form of theft and could be lawfully pursued as such.

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Excessive roughness during care and failure to provide adequate care that is expected to be the standard of such a facility constitutes the occurrence of physical abuse and neglect. Failure to provide privacy to the resident during care would indicate neglect and psychological abuse that would result in anguish and person distress to the resident. Taking any property of a resident without due cause for the provision of care or safety is considered theft and would be prosecuted as such an action in a court of law.

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Restricting a residents freedom of activity, movement and ensuing confinement would be viewed as false imprisonment and could be pursued in a court of law. Preventing a resident to make choices within the realm of their mental and psychological capacity would be construed as inhibiting the rights of the resident to freedom of choice and inhibiting the resident’s right to make decisions for themselves.

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Purposeful humiliation of a resident with name calling or making fun of them within the ear shot of other residents, staff or visitors is considered mental and psychological abuse. Hiding a residents property or personal belongings from the resident without cause of ensuring safety would be viewed as theft and misappropriation of the resident’s personal effects.

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Education is one of the key points to preventing abuse in the PCH setting along with appropriate staffing levels and frequent reassurance of the staff and recognition of a job well done. Allowing the staff to know that they are appreciated for the work they do and the care they provide is essential to have the staff feel needed and wanted by both the administrative personal and the residents.

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Providing staff with the tools needed to cope with the type of residents that they care for is necessary to help them understand the behaviors' of the individual in their care.

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Careful selection of staff and proper pre-employment background checks are essential to assure that the facility hires those individuals that will provide safe, respectful care to the residents. Random drug testing, staff education and careful observation of new staff can prevent the occurrence of abuse.

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The signs and symptoms of abuse and neglect are not always readily noticed, they may be subtle and go unnoticed for a considerable time until physical impairments or injury are evident.

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Fear of a caregiver is a true indication that the resident has experienced an unfavorable situation with this caregiver and needs to be investigated by the administrative staff in the facility.

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Investigation of all suspected crimes are necessary to assure that abuse, theft or neglect has not occurred.

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The reporting of suspected abuse with physical evidence and those incidents witnessed are to be reported within 24 hours of the occurrence. The first line of reporting by other staff, residents and visitors is to report suspected cases of abuse to the supervisor for investigation. If the abusive act is eye witnessed, then the individual can report the incident to the state themselves on the abuse hotline.

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There should be recorded any unexplained bruising, bleeding skin tears, painful areas that are unexplained. Other reportable signs and symptoms would include a change in behavior, residents that excessively quiet and do not want to leave their room, a resident that displays fear with a particular caregiver and reports of threatening and intimidation of a resident by an other resident or family member.

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If sexual abuse is suspected, the resident should not be bathed, refrain from using cleaning aids that would jeopardize the integrity of fluids that may be present and maintain the integrity of the resident’s clothing.

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Double billing and bogus charges incurred by the resident and family are types of fraud that can occur with in the PCH setting. The Insurance providers will investigate charges that seem too high or for treatments that are not in the realm of the resident’s diagnosis or plan of care

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The insurance provider will also investigate the need for excessive amount of medications and will refuse to pay for these medication, then in turn the medication costs will be reflected in the resident’s personal charges and sent to the responsible party. The resident or the family/POA are entitled to a detailed explanation of the medication use and provision of care that required the need for additional medications.

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During the green light period the resident’s exhibit that they are cared for under the standards that are expected of the facility and that the staff is well trained and capable to provide safe care for the frail elderly and those with special needs within their facility.

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At this point the administrative staff should investigate the resident’s course of injury, observe the resident’s care and identify individuals and situations that could be identified as suspected abusive actions and inappropriate. Education measures should be instituted to provide the staff with the tools needed to care for the residents at the facility and assure that there is proper staffing for the number of residents and the acuity of the care needed. Administrative staff should oversee the care of the resident in question and assign the same care giver to the resident whenever possible to provide the resident with continuity of care and proper management of the resident’s plan of care.

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It is the administrator's responsibility to provide a safe environment for the residents in their care and to prevent the occurrence of abuse, theft and neglect. The facility should provide an honest account of all the resident’s care and the appropriate charges that are involved in that care to assure that there is not cause for financial concern or misappropriation of funds. Staff that are suspected of unnoticed abuse and threats of retaliation of punishment should be terminated and reported to the proper authorities. If theft is suspected, the goods or personal items should attempt to be recovered be it that another resident or staff member attained the stolen property and lawful actions should be taken with the proper authorities.

Slide 1

NEGLECT, ABUSE AND FRAUD PREVENTIONIN THE PCH SETTING LHHC PCH EDUCATION SERIES FOR PCH ADMINISTRATORS 1

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OBJECTIVES At the end of the course the learner will: Define the different types of resident abuse. Describe methods for identifying the occurrence of abuse. Describe methods to prevent abuse. Describe methods for reporting resident abuse and/or a suspicion of a crime. Identify the appropriate agencies for reporting resident abuse. 2

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What constitutes abuse? Abuse has many faces and many methods Abuse can be subtle and unnoticed by those individuals in the elderly resident’s surroundings Abuse can range from actual physical abuse, self-neglect, verbal abuse, emotional abuse, financial abuse, abandonment and withholding care. 3

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Abuse vs. neglect Abuse is a deliberately planned mistreatment or harm to another person. Abuse can be unintentional, this type of abuse occurs when the caregiver lacks adequate knowledge to provide appropriate care measures and a safe living environment. Unintentional abuse can also occur when the caregiver is excessively tired, frustrated or under stress in the care of the resident. 4

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Abuse vs. neglect Neglect is a passive form of abuse when a caregiver fails to adequately provide for the needs of the resident. Neglect can include lack of provision of proper hygiene, nutrition, safety provisions or adequate medical care. 5

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Abuse vs. neglect In the Personal care setting, an act of neglect would be constituted by the facility’s lack of ability to provide adequate physical and nutritional provisions due to daily caregivers lack of knowledge and improper training with regard to caring for the frail elderly and those with special needs. 6

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ABUSE vs. neglect Abuse and neglect are related terms that put the frail elderly and those with disabilities or special needs at risk for harm whether it be intentional or unintentional. Most abuse and neglect situations go unnoticed until there is behavioral changes or physical signs in the individuals being abused or neglected. 7

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Abuse in the healthcare setting Abusive behaviors by caregivers can consist of: Use of sedatives or medications that diminish physical alertness or independent activity without medical cause. Use of derogatory language, angry verbal interactions or ethnic slurs, and willful actions that constitute making fun of humiliating a resident for their condition or physical disparity. Withholding privileges such as snacks or cigarettes. Consumption of the resident’s food or personal food items. 8

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Abuse in the healthcare setting Excessive roughness in handling during care or transfers. Delay in taking residents to the bathroom or allowing a resident to lay in body waste as punishment of soiling themselves. Unlawfully taking money or personal belongings from the residents Failure to provide privacy. 9

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Abuse in the healthcare setting Unnecessary use of restraint such as restricting the resident’s mobility, locking doors so the resident cannot freely leave and/or blocking the resident’s door so that they are not able to freely exit the room. These actions are all construed as involuntary seclusion. Violation of the resident’s right to freely make decisions or restricted freedom within safe parameters. 10

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Abuse in the healthcare setting Mental abuse is defined as but not limited to humiliation, harassment, threats of punishment or withholding of treatment or services. Misappropriation of the residents property is defined as deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without the resident’s consent. 11

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Abuse in the healthcare setting Abuse and neglect are more likely to occur in the PCH setting when the caregivers feel they are not valued, supported or acknowledged for the quality of care they provide. The incidence also increases when the caregivers are forced to work in stressful conditions with a poor ability to deal with stress or in situations of poor staffing and/or resident overload. 12

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Ways to decrease stress and the likelihood of abuse in the PCH environment. Improve staff training to identify and defuse potential abuse situations. Recognize the value of the caregivers in the PCH and reward and praise those caregivers that provide compassionate, attentive care to the residents. Start with recognition of caregivers with an employee of the month or similar recognition program that will provide an example of good resident care. 13

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Government measures to prevent abuse and neglect Government agencies provide safeguards to prevent abuse in the elderly or for persons with special needs by providing measures to prevent individuals with a criminal background or previous abuse history from gaining employment in the capacity of caregivers. This is accomplished with criminal background checks and detecting history of abuse or neglect. 14

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Signs indicating abuse or neglect The residents demonstrate excessive agreement or compliance with the caregiver. The resident may exhibit signs of malnutrition or dehydration The resident demonstrates signs of poor hygiene, uncleanliness or soiled clothing or undergarments. The resident has unexplained bruising, particularly clustered on the trunk or upper arms. 15

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Signs indicating abuse or neglect The resident may have bruising at various stages of healing that may indicate repeated abuse. The resident verbalizes being left alone, isolated or held against their will. The resident may verbalize fear of the caregiver, this is not done publically with fear of retaliation. 16

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The resident may report personal items missing or money that is missing. The resident may verbalize hunger and thirst and demonstrate signs of dehydration and weight loss. The resident may demonstrate signs of increased depression or withdrawal and introversion without medical cause. The resident may demonstrate excessively quite behavior in the presence of certain caregivers. 17 Signs indicating abuse or neglect

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Actual or suspected Resident abuse or neglect In the case of suspected or witnessed abuse or neglect, the PCH administrator should collect the following information: The name of the resident in which the abuse or suspected abuse occurred. The date and time the incident occurred. Where the incident took place. The name of the accused abuser and any witnesses of the incident. 18

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Actual or suspected Resident abuse or neglect The type of abuse that occurred and a detailed account of the circumstances. Upon receiving the report of physical or sexual abuse, the resident should be examined by a licensed professional and the examination findings recorded. 19

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Actual or suspected Resident abuse or neglect In order to obtain accurate finding, the resident should not bathe, and resident’s clothing should not be washed or altered in any way. Items should not be removed from the area of the incident to maintain the integrity of the investigation. There should also be a detailed account from anyone witnessing the incident and identification of those individuals obtained. 20

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Fraud in the PCH setting The most common type of fraudulent activity that can occur in the PCH setting is misappropriation of funds or fraudulent acquisition of over payment, funds that acquired from supporting payers when the individual has already personally paid for services rendered. This can occur with fraudulent charges for services not received or offered. 21

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Fraud in the PCH setting Medications that unlawfully utilized for the purpose of medicating other residents or those medications that are unlawfully taken by the staff for personal benefit. Resident’s personal money that is taken by the staff or caregivers for personal use. Allowing other residents to take the personal property of a particular resident without their consent. 22

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Fraud in the PCH setting In cases of suspected fraud, the resident’s family, POA, or resident representative can request an investigation for unlawful acquisition of Medicare or Medicaid funds with the intention of receiving duplicate monies that have already been paid by the individual resident or the resident’s family. This type of action is also known as “double dipping” and constitutes theft. 23

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In the green light action plan, recognize that residents are provided the care they require without undue injury or unexplained signs and symptoms of injury. The resident’s weight remains stable and their physical condition continues to improve or remains stable. Continue to provide the needed care measures and continue to consistently assure a safe environment for the residents and staff. Green Light Action Plan

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The yellow light action plan would be initiated when there is a suspicion of actions that could constitute abusive behavior. This is when the resident has unexplained bruising, skin tears, repeated reports of the resident “bumping into things and sustaining injury", and evidence of repeated injury that goes unreported. Noticing that a resident is fearful of a particular caregiver or family member. Yellow Light Action Plan

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The red light action plan would include investigation and reporting of suspected abusive situations to the proper authorities. Seeking professional examination of the resident to obtain an accurate account of injuries and frequency of abusive actions. Termination of suspected staff to assure safety of the residents and prevent retaliation of punishment to the resident in question by the staff member. Involve local and government law enforcement, with trial to the extent of the law. Red Light Action Plan

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Summary In order to assure that resident funds and payment is lawfully obtained and maintained at the level that the resident was provided at the time of admission, the PCH should keep accurate financial records of all funds received and the distribution of those funds in the course of the resident's care. All medications should be documented when they are dispensed and in the proper dosage. 27

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Summary Resident’s should be provided a secure vessel that can be locked to keep money and other valuable items during their stay at the facility. The family and/or POA should be encouraged to keep valuable items in the home or provide the resident with a safety deposit box in which to keep valuable items while in the PCH. 28

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Summary In conclusion, it is the responsibility of those individuals that are in the supervisory role to provide a safe environment for the frail elderly, those with physical or emotional disparities and the cognitively impaired when in the confines of their care. It is the responsibility of the governing staff to provide efficient, honest caregivers that will provide the necessary services to keep the residents safe and within a reasonable health state for the time they are under the care of the facility. 29

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Summary Caregivers should have a criminal background check and investigated properly to assure that they do not have a history of abuse or neglect to assure the best quality care for the residents. Following government standards, employing reliable, honest staff and providing services as outlined at the time of admission, will maintain a safe comfortable environment for the residents and caregivers. 30

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Where to get help or report elder abuse www.aging.state.pa.us Elder Abuse: Recognize the Signs (PA. Department of Aging) Toll Free Hotline: 1-800-490-8505 31

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Your local Area Agency on Aging has support counseling and referral services available to help you. The following organizations can also provide information on caregiving and support services. Aging and Disability Resource Centers 1-866-286-3636 (toll free) Where Can You Get Help? 32 Apprise 1-800-783-7067 (toll free) Children of Aging Parents P.O. Box 167 Richboro, PA 18954 1-800-227-7294 (toll free) Long Term Care/Alzheimer’s Helpline 1-866-286-3636 (toll free)

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