To investigate nursing home abuse, you must first understand what "abuse"
actually is, where it comes from and the characteristics associated with
the abuse. According to the Funk and Wagnall's Standard Dictionary, abuse
is "to use improperly or injuriously; to misuse, to hurt by treating
wrongly; to injure or to speak in coarse or bad terms." When applied
to nursing homes, it is to intentionally mishandle or to verbally degrade
a person. For the most part, the abuse is an intentional action or actions
that have formed a pattern in which the person is treated. Let's face
it, accidents happen to everyone in every type of job and situation. However,
abuse is going beyond an "accident" and has a direct correlation
to the mental frame of mind or condition of the persons(s) involved.
By the time a person finds themselves in a nursing home, they have
usually reached a sense of helplessness and are insecure about themselves
and their future. Although this topic is not a laughing matter, I am often
reminded of the elderly patient who indicated that they go to the bathroom
regularly at 6:00 a.m. every morning. Unfortunately, they are not awake
when they do! This is just an example of how the elderly become dependent
on those around them in their later period of life. These people, for
the most part, have worked a long life and only hope that they can leave
this world with a little bit of respect and dignity. It is bad enough
that they lose control of their bodily functions and motor skills, but
being the victim of abuse is more than any of these people deserve.
Abuse can come from a variety of causes, however, all abuse has the
same characteristic of an intentional action. Regardless of the reason,
a willful intent is a fundamental characteristic for the abuse to have
occurred. Unfortunately, some people are unhappy with their own lives
and they take this out on everyone around them. The elderly are an easy
target because they are weak and defenseless. In many cases, the patient
has had a stroke or other medical condition that has caused them to lose
their speech or their motor skills. When a person is unable to speak or
to resist, the patient can often times become a target of the abuse.
There are many forms of abuse including verbal, emotional and physical.
Some of the more commonly found types of abuse include:
-Verbally degrading the patient;
-Verbally threatening the patient;
-Emotionally manipulating the patient;
-Emotionally threatening the patient;
-Physically injuring the patient;
-Physically manipulating the patient;
-Sexually abusing the patient.
VERBALLY DEGRADING THE PATIENT
This is one of the more common types of abuse found in nursing home
facilities. It is common for the staff of a facility to yell and scream
at other employees, as well as the patients in their care. When confronted
with this, the staff usually falls back on the catch-all defense of "the
person is hard of hearing." It is one thing to increase the volume
of one's voice, but it is another thing to scream degrading remarks at
the person. One of the more common ways that we see a patient degraded
verbally is when they are told that if they don't eat, the employee will
shove the food down their throat. There are proper ways to tell a person
what you want them to do and this is not one of them.
Many of the nursing home employees are kind to the patients and speak
kindly when they clean them by telling them such things as, "you have
such pretty hair." However, it is also common for the employee to
tell them degrading remarks about their condition or their inability to
control their bodily functions. The elderly are often frightened and disoriented
by being in a nursing home. Having someone speak rudely or harshly towards
them causes the patient further discomfort. The elderly feel defenseless
in these situations and are just happy to have someone who will pay a little
attention to them, regardless of the abuse. Many of the facility employees
know that the elderly are threatened by them and are therefore not concerned
with treating the person with respect and dignity. Every nursing home
has employees who verbally abuse their patients and most overlook the employee's
actions because they at least show up for work or they pass it off as the
person having a bad day.
VERBALLY THREATENING THE PATIENT
Verbal threats are very similar to verbal abuse in general, however,
they tend to be directed much more towards a particular patient and are
more intense than normal verbal abuse. When an employee degrades a patient
by telling them that they don't like the person wetting all over themselves
while using a sarcastic voice, that is verbally degrading.
However, when an employee tells the patient that they are going to
spank the person if they keep wetting the bed, this becomes a type of verbal
threat. The patient does not have control of their bodily functions and
can therefore not prevent or control this situation. Another type of common
verbal abuse is when a staff member tells the patient to eat or they will
shove the food down their throat.
EMOTIONALLY MANIPULATING THE PATIENT
An elderly person who is insecure about their situation and condition
is a prime candidate for emotional manipulation. An example of this comes
to mind. The President of the United States decided to stop in a nursing
home to conduct some public relations. One of the elderly patients carried
on a conversation with him for a while and the President finally asked,
"you don't know who I am, do you?" The patient said, "no,
but if you will go to the nurse's station over there, they will tell you
who you are." This is a simple way of depicting how a patient can
become insecure about their surroundings.
The patient has the primal instinct to be around other people who they
feel will protect and care for them. Facility employees know that a patient
will often endure hardship just to have someone around them. People are
born with the desire to be touched and communicated with. When the elderly
do not have enough of this attention, they are easily manipulated. In
some cases patients can be emotionally maneuvered into overlooking the
abuse of the staff in fear of not receiving the necessary attention that
EMOTIONALLY THREATENING THE PATIENT
A patient is emotionally threatened when they have had certain circumstances
occur which they perceive as a threat and which keeps them from speaking
out against the threat.
When a patient observes another patient being mistreated and no one
doing anything about it, they begin to become emotionally threatened into
realizing that they have no control over their situation and must therefore
keep silent to prevent themselves from being a target. The patients are
quick to observe the treatment of those around them and it doesn't take
long to understand that they are emotionally at a disadvantage.
PHYSICALLY INJURING THE PATIENT
There are many ways that a patient can be physically injured while
in a nursing home. Dropping or mishandling a patient are fairly routine
in most facilities. Although handling a person in certain ways may not
be considered rough on a younger person, when applied to the elderly, it
can definitely be abuse. The elderly have problems with brittle bones
and are fragile to begin with. When an employee tosses a person onto the
bed, it is not uncommon for the patient to dislocate their hip or break
Because the skin of an elderly person loses it's elasticity, their
skin can be torn and cut with the least amount of effort. Once again,
failing to take extra care while handling the person can cause the skin
to be damaged.
Almost all nursing homes are understaffed, which prevents the patients
from being routinely turned to prevent bed sores (pressure sores). This
physically injures the patient and the pain has been described as being
similar to an ulcer in a person's mouth but even worse. When a bed sore
is left untreated, it turns into a sepsis (open wound) where infection
occurs. These patients often are left unchecked and lay in their own urine
which further irritates and contaminates the sepsis.
Another type of physical abuse is grabbing a patient by the cheeks
and attempting to force-feed the subject. The patient may not like the
food and most facilities try to provide a secondary meal for these situations.
Unfortunately, the person may be abused by forcing them to eat.
Nursing home facilities are not the same and do not have the same bathroom
facilities. Some may have individual bathrooms and bathing facilities,
however, for the most part, most only have 2-5 baths and or showers. Because
of the lack of bathing facilities, the patients may not receive proper
cleaning, which is another type of physical abuse.
PHYSICALLY MANIPULATING THE PATIENT
A patient can be physically manipulated into performing or conducting
certain actions that they would not customarily perform. As an example,
the patient may be coerced into moving or standing against their will based
on a firm grip or pinch by a staff member. These types of employees attempt
to get the patient to move at a faster rate or in a manner that they feel
appropriate by pinching or strongly grabbing the person. The attitude
is that they cause the person to perform the desired activity without leaving
a physical mark on the person.
SEXUALLY ABUSING THE PATIENT
A patient who is mentally slow, physically unable to speak or unable
to defend themselves may become a victim of sexual abuse. These attacks
may come from a staff member, another patient, a family member or a complete
stranger. Even when it comes from a staff member, other employees are
often too busy to notice unusual signs or they may neglect to report the
incident out of fear. The nursing homes are typically co-ed and it is
not uncommon for relationships to develop as it would in any male-female
setting. However, when one patient sexually abuses another, this moves
outside of a normal relationship just as it would in any other social setting.
Family members may miss the affection and relationship with their spouse
who is a patient. When this occurs, they often attempt to continue their
sexual relationship. Unfortunately, the medical conditions as well as
physical, mental and emotional status of the relative may cause the intercourse
to be painful. When this occurs against the will of the spouse, it moves
into the area of sexual abuse. In some situations, the nursing home staff
will not do anything about it based on the fear of reprisals due to the
legal relationship between the couple.
In a nursing home setting, abuse can come from a variety of persons.
This includes the owner(s) of the nursing home, the administrator of the
nursing home, the staff of the facility and the family members. In addition,
abuse can come from other patients (or residents as they are commonly called)
or even someone off of the street. The State Licensing Board is usually
a promoter of this activity. The following will attempt to describe how
each of these can be involved in abuse of nursing homes.
NURSING HOME OWNERS
The owners of a nursing home can be a variety of people with a diverse
background. They may be doctors, independent businessmen, large corporations
or family owned operations. As in many industries, the nursing home industry
is seeing many of the small homes being bought out and placed with a large
conglomeration of other nursing homes under a central corporation. One
can be as bad as the other. The smaller owners have less cash flow, while
the larger corporations provide less personal contact. Unfortunately,
all of the owners are forced to recognize that it is a business and they
make decisions based on profit, which affects the treatment, staff and
supplies available to the patients. Large corporations typically have
stockholders which demand as much profit from the homes as possible. Because
they are large, an impersonal approach often develops, making cutting services
to increase profit even easier. This impersonal attitude permeates into
a lack of control. The lack of control allows administrators to carry
on without proper supervision. The lack of supervision transfers into
a lack of patient care, which turns into abuse.
The owners of nursing homes are known for hiring minimum wage employees
who typically have minimum education. Even the Licensed Vocational Nurses
(LVN) and the Registered Nurses (RN) that work at the nursing homes are
often sub-standard when compared to other LVN's or RN's employed in hospitals.
Because the owners can hire employees to do the job at a minimum pay level,
they continue to do so. In reality, if they would increase the rate of
pay, the quality of employees would increase which would ultimately translate
into better care, more profits and less lawsuits.
The owners of these facilities seldom, if ever, conduct any type of
background investigations on the potential employee. During our investigations,
we have found that many of the employees go from one nursing home to the
next. When someone is terminated for abuse or something similar, they
simply move on to the next nursing home who is more than willing to hire
someone already "trained" in the industry. Failing to conduct
appropriate background checks has resulted in the industry cultivating
an atmosphere of abuse. We have seen situations where an administrator
becomes known for hiring those who have had conflicts with the law and
these people flock to the administrator who is more than willing to hire
The bottom line with the majority of nursing home owners is the profit
margin. They lose sight of the care and become too concerned with making
a profit and end up promoting the problems which are ruining the industry.
THE NURSING HOME ADMINISTRATION
The administrators at a nursing home facility ultimately determine
the care or abuse that the patients obtain. If they allow abuse, neglect
and poor care to occur, they are in essence promoting this type of treatment.
Often, the administrators intentionally try to shield themselves from
the rest of the staff so they can state that they did not know that a situation
was occurring. Most administrators are known for staying in their office
and seldom walking the hallways to see what is actually going on. These
same administrators tell the supervisors who advise them of a situation
that they "will take care of it" and then never take any action.
After this occurs over and over again, the supervisors stop telling the
administrators because they know nothing will be done. This is exactly
what the administrators want because they can once again blame the supervisors
and cry that they never knew about the abuse.
The administrators fail to order supplies in an effort to please the
owners by keeping supply costs down. I have seen situations where the
administrators told employees to stop wearing gloves when working with
patients because they were costing too much. During our investigations,
we find where supplies are limited until just before the State Auditors
came in to perform an audit. They usually have a closet with new sheets,
towels, linens, etc. stocked, and will take these out just while the auditors
are there and then will take the supplies away afterwards.
The administrators will often order their employees to fill in the
blank spaces on charts so that it will not stick out when the State Auditors
arrive. This attitude then tells the staff that they can cheat or break
other laws since the administration is encouraging this activity.
Our investigations have typically shown that the administrators of
a facility often are caught in the middle. They are being pressured by
the owners to produce profits while the staff treats them like an enemy
as well. The stress from both sides often causes the administrator to
hide in their office away from both sides.
THE NURSING HOME STAFF
The employees of the nursing home are the ones who ultimately have
the most contact with the patients and are therefore the ones who are most
likely to abuse the patients. Their actions, however, are allowed and
cultivated by the actions of the facility owners and the administrators.
During our investigations, we are often told that the employees do the
things they do because they observed the Director of nurses or the Charge
Nurse engaging in the activity.
The employees are minimum wage earners who usually have a poor self-esteem
and take life's frustrations out on those who can't defend themselves.
In all fairness, these employees are overworked and there is a shortage
of staff which causes their tolerance level to decrease. Some of the patients
can become a little violent when they are ill or tired and the staff often
has to guard against patients who will vent this towards the staff. However,
if trained properly, they should know how to deal with this issue.
Although abuse by family members is very rare, it does happen. In
one case, a lady was a patient in the nursing home and her husband would
come in and have intercourse with her. The patient had a foley tube and
the employees would hear her moaning and crying due to the intercourse
causing her pain. Although the staff heard and knew, no one tried to stop
this from occurring. In abuse by family members, the abuse usually escalates
into some type of physical violence which was a result of a continued problem
between the two. This is even more likely to occur due to there being
so many employees in and out of rooms. Even though this is very rare,
this issue should still be considered based on the merits of the investigation.
ABUSE BY OTHER RESIDENTS
One patient abusing another patient occurs from time to time and needs
to be addressed as a possibility. When a patient has had a stroke or other
medical condition that prohibits them from speaking and/or moving, they
can become a target of abuse. Patients can steal from these subjects,
pinch, hit or sexually abuse this type of resident. In one case, a patient
was sneaking around sexually abusing patients who were not mentally coherent.
ABUSE BY STRANGERS
Many nursing homes lack in security and in some of the facilities located
in crime-ridden areas, they become a target. When you have transients
in the area, they will often try to sneak into the homes to use the bathroom
and showers or to get out of the heat and cold. Although their original
intent may have been somewhat harmless, crimes occur due to an opportunity
Most nursing homes have doors located on all four sides of the structure
which are not observed on a regular basis. The homes generally have policies
indicating that all of the doors except the front door have to be locked
after a certain period of time. However, employees use these doors to
step outside to smoke and do not concern themselves with the security of
In some cases, an employee has had their spouse come to the facility
in anger and causes harm to all who come into contact with them before
the police can arrive. Once again, a lack of security in these facilities
allows these things to occur.
PROMOTION OF ABUSE BY THE STATE BOARD
The State Health Board or a similar licensing board regulates the nursing
home facilities. Part of their job is to inspect and audit the facilities
using surprise visits. In every case we have encountered, the nursing
homes knew in advance that an audit was coming. Having foreknowledge allows
the administrators to pull out the new linen and supplies that they never
use. In addition, this allows the administrators to cover their tracks
by filling in charts, adding time sheets to make it appear that there are
more employees and similar set-ups. This type of activity promotes the
entire abuse situation.
As you can see, abuse stems from a variety of persons and may not be
just the physical attack of a person. Failing to provide for the care
and custody of a patient who is in the nursing home's care can move into
the area of abuse. The emotional, physical and mental capabilities of
each person involved plays a role in determining whether the action, or
lack of action, is actually abuse. In addition, the intentions of the
parties involved also have an effect on whether abuse has occurred or not.
1997 by Kelly E. Riddle
Reprinted with permission, from
Nursing Home Abuse Investigations,
Chapter 1, ISBN 1-891247-04-2.
Kelly Riddle has worked in both law enforcement and private investigations,
where he has developed expertise in insurance-related investigations, general
liability and product liability cases. Kelmar and Associates conducts
a variety of investigations including counter-intelligence, workplace and
Recently selected as "Investigator of the Year" by the National
Association of Investigative Specialists, he has been listed as "one
of the top surveillance experts in the United States today." Kelly
is also a frequent guest speaker and lecturer who has appeared on various
television and radio shows, and has been published in numerous publications.
You may contact Kelly at Kelmar & Associates in San Antonio, TX
(210)342-0509, or via e-mail at firstname.lastname@example.org.