ELDERLY ABUSE IN NURSING HOMES

By Christie Fischer

I.  INTRODUCTION

Of nursing home staff in 1989 40% admitted to committing at least one psychologically abusive act toward a resident and 10% admitted to physically abusing a resident in the preceding year.[1]  Not only are nursing home residents at risk of being abused by their caretakers but they are also at risk of being restrained, which may lead to a form of abuse. With five percent of the elderly population, or one to two million instances of elder abuse occurring yearly there is no doubt that elder abuse deserves serious consideration.[2]

Upon growing older there are many decisions to be made.  Among one of the most difficult and perhaps most important decisions is where the elder person will live and how long-term care needs will be met when he/she is no longer capable of doing so independently due to the incapacity that accompanies many with old age.  Nursing homes seem to be the popular choice for people no matter the race, gender, or socioeconomic status with 1.5 million Americans being admitted to them yearly.[3]  Because nursing homes are in such a high demand and are not cheap, $77.9 billion was spent for nursing home care in the United States in 1995 alone, they are under criticism of many professions including the legal profession, which is in the process of establishing elder law as a defense to issues with in the elder community.  Nursing homes have a duty to provide many things to the elderly including medical, social, pharmaceutical, and dietary services so that the individual may maintain the highest well-being possible.[4]  Stated another way “a nursing facility must care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident.”[5]  Although there are many requirements in place to determine the standards nursing homes are to meet, like any other profession, policies are not always followed and unwanted conditions occur. Of the conditions in nursing homes elder abuse may not be the most frequent but it should be one of the most prevalent in being solved due to the effects it has on the elderly and everybody who surround them. 

II.                THE FOCUS OF THIS ARTICLE

The population of elderly is growing and with that the need for long-term care facilities in which to place the elderly is also growing.  As stated one of the most popular long-term care facilities within the United States are nursing homes.  Due to contributing aggravating circumstances the elderly have become subject to abuse within some nursing homes. Abuse can take place in many shapes and forms including, but not limited to, verbal, physical, psychological, and abuse due to the use of restraints.  This article is not meant to portray that all nursing homes or all nursing home employees are abusive to their residents.  This article lays out the minimum requirements that nursing homes must meet and explores the abuse that has occurred and is continuing to occur within the nursing home setting.  It also attempts to examine some alternatives that are available in order to help nursing homes and society in general to better their positions so that the elderly will not have to endure the unnecessary and horrible abuse and conditions that occur with it. 

III.             DEFINITION OF ELDER LAW 

            Elder law may be defined at “the legal practice of counseling and representing older persons and their representatives”.  It is a holistic and interdisciplinary approach to the practice of law, which looks prospectively toward the remaining portion of life by anticipating the problems that are yet to occur.[6]  Since elder law is such a fairly new concept in the field of law many people, including attorneys, may be perplexed as to what exactly is meant by the words elder law.    Charles P. Sabatino, an Assistant Director of the ABA Commission, has provided three criteria to help define the term elder law.  These include special emphasis on issues 1) pertaining to long life, 2) legal planning combined with the big picture of planning needs, and 3) maintaining an interdisciplinary planning perspective. These three broad areas contain many subcategories including, but not limited to, health and personal care planning, pre-mortem legal planning, fiduciary representation, legal capacity counseling, public benefits advice, advice on insurance matters, residents’ rights advocacy, housing counseling, employment and retirement advice, income, estate and gift tax advice, counseling regarding to age and disability discrimination, and litigation and administrative advocacy in connection with any of the above mentioned.[7]  Also contained within the meaning of elder law is abuse that transpires within the places that are supposed to be caring for and maintaining the health and safety of the elderly- that is nursing homes. 

IV.                          REQUIREMENTS FOR NURSING HOMES

With the federal government paying for nearly 56% of nursing facility costs through Medicare and Medicaid it now plays a prominent role in determining the nursing home standards and state regulatory agencies due to the Nursing Home Reform Act of 1987 (NHRA).  Congress enacted this as a comprehensive framework for regulation of nursing homes that participate in the Medicare and Medicaid programs and to prevent states from taking a passive approach as to elder abuse in federally funded facilities.[8]  This act sets forth the minimal standards that nursing homes must abide by and helps to ensure high-quality care for the elderly.  Since these are the minimal standards to be followed states are free, as they have done, to enact their own requirements for nursing homes.  The federal requirements for nursing homes are laid out in 42 U.S.C.A. § 1396r. 

Once a facility meets the definition of a “nursing facility” as laid out in 42 U.S.C.A § 1396r  it must also meet the requirements that follow it.  These include forming a quality assessment and assurance committee, providing for a 24 hour licensed nurse, regular performance review and regular in-service education to employees, availability of a physician, have qualified employees, require health care of every resident be provided under the supervision of a physician, maintain clinical records, and if it contains 120 beds then to have a social worker employed.   Providing services and activities to maintain the highest practicable well-being of each resident, conducting a comprehensive assessment of each resident’s functional capacity describing the residents daily life functions and identifying medical problems, reexamining the patients and their abilities, and to provide a patients bill of rights are also included in the NHRA.   Under this act a nursing facility must also protect and promote the rights of each resident, including freedom from abuse and restraint, which is what this article will focus on.[9]  42 U.S.C.A § 1396r  states that it is the patients “right to be free form physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms.  Restraints may only be imposed 1) to ensure the physical safety of the resident or other residents, and 2) only upon the written order of a physician that specifies the duration and circumstances under which the restraints are to be used (except in emergency circumstances).” 

Federal surveillance of the effectiveness of state regulations is provided for by NHRA.  Nursing home surveyors rely on the Health Care Financing Administration guidelines to evaluate compliance with the federal requirements.  These surveyors evaluate the appropriateness of the nursing homes behaviors and compliance is measured by outcomes.  The NHRA provides for the federal standards of care nursing homes are expected to achieve in order to receive federal funding.[10] 

V.                             TYPES OF ABUSE

Elder abuse may be difficult to identify because it can take the shape of different forms and be conducted through several different behaviors.  The United States Department of Health and Human Services has identified seven categories of elder abuse.[11]  These categories include:

1)      Misuse of restraints- chemical or physical control of a resident beyond a physician’s orders and/or not in conformity with an accepted medical practice;

2)      Verbal/emotional abuse- infliction of mental or emotional suffering;

3)      Physical abuse- infliction of physical pain or injury which includes sexual abuse;

4)      Personal property abuse- illegal or improper use of a resident’s property by another for personal gain;

5)      Verbal/emotional neglect- creating situations in which esteem is not fostered;

6)      Physical neglect- disregard for the necessities of daily living; and

7)      Medical neglect- lack of care for existing medical problems.[12]

The definition of elder abuse is not set in stone and may vary from state to state with only the most obvious abuse cases being recognized.  For example, California law defines it as “physical abuse, neglect, fiduciary abuse, abandonment, isolation or other treatment with resulting physical harm or pain or mental suffering, or the deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering.”  Arizona law defines it as the “(a) Intentional infliction of physical harm; (b) Injury caused by negligent acts or omissions; (c) Unreasonable confinement; or (d) Sexual abuse or sexual assault.”[13] The definition of the types of abuse may vary not only from state to state and facility to facility but also from person to person.    Because the federal government has not given a concrete definition of elder abuse it is difficult to determine when it occurs and to what extent it is occurring. 

            Since abuse is so difficult to define it may be helpful to look at the most frequently received complaints.  The nursing home resident has the right of access to a state ombudsman under the NHRA.   Under this right an objective third party receives and investigates claims made by a resident or on behalf of the resident.[14]  In 1995 the Long Term Care Ombudsman Annual Report reported that 86.7% of the complaints it received originated from nursing homes.  From 29 of the reporting offices the most frequently received complaints consisted of accidents and improper handling, dignity, self-respect, attitude, menu quality, personal hygiene, requests for assistance, care plan and resident assessment, shortage of staff, discharge planning, personal property lost, symptoms unattended to, physical abuse, medication deficiencies, cleanliness, family conflict, filling notice, odors, roommate conflict, legal guardianship and staff unresponsive or unavailable.[15]  Although this list of complaints does not clarify what is meant by the term elderly abuse it does help to put into perspective what residents and others who surround them consider reportable abuse. 

VI.                          REASONS FOR ELDER ABUSE

As stated there are many types of abuse but just as important, if not more important, is looking at why the abuse is occurring in nursing homes.  When looking at stopping elder abuse it is important to look at why it is occurring in order to appropriately identify and correct the situation with the greatest efficiency and approval rate.  But just as there are several types of abuse which are difficult to define the reasons behind this abuse may vary even more greatly and therefore be even more difficult to determine. 

While elder abuse is as prevalent as child abuse it is less likely to be reported with only one of every eight cases being reported compared to one of every three cases of child abuse being reported.  One reason for failure to report elder abuse in nursing homes is the vulnerability of the resident.  Often these people are alone with no relatives or friends to depend on let alone demand that the elder person get the quality care he/she deserves.[16]  This leaves the resident feeling lonely and uncomfortable and unwilling to deal with the idea of reporting the only people who fill the emptiness, even if that means enduring the needless and horrific situations of abuse.  The victim may also fear that the abuse will continue or become worse if it is reported and the abuser knows of the report.  Because of the loneliness and fear of further abuse it may go unreported and continue to occur. 

Many elderly suffer from diseases and incapacitates that leave them weak and unable to stand up for them selves therefore the elderly person may suffer from a sense of powerless as to the abuse. These victims of abuse may be embarrassed to report the abuse because this will show their weakness, which is not valued trait in the American society.[17]  Not only do elderly suffer from a sense of powerlessness but some are literally left powerless by the fact that their disease has taken their communication skills from them and therefore the person is unable to communicate the abuse that is taking place. The sense of helplessness felt by an elder person after his/her independence has been taken away and he/she is placed in a nursing home is one of great concern but adding abuse, no matter what type it is, greatly enhances this feeling of powerlessness.  Due to this feeling of powerlessness, helplessness, and sense of loss of control the elderly are less likely to report abuse and it continues to take place within the nursing home setting. 

Although the above mentioned reasons for the continuation of elder abuse in nursing homes looks towards the resident and what the resident may be feeling they are in no way meant to convey that it is the elder persons fault the abuse is occurring.   What these stated reasons are meant to convey is an understanding of why and how such horrific conditions of abuse, such as the report in California that reported from 1986 to 1993 of all the nursing home residents who died 7% succumbed to neglect in some way[18], goes unreported and therefore may continue on several different residents and become extremely severe.

            Other accounted for reasons of elderly abuse in the nursing home deal directly with the nursing homes and its employees.  Nursing home facilities may be under-financed due to the combined effects of high costs of providing services, lack of funds that the elderly possess and the lack of funds the federal and state budget are able to set forth for the support of the facilities.  Because a facility may be under-financed it is forced to make cuts in its operation budget, which directly affect the residents and prevent them from getting high quality care.  Facilities may choose to cut the budget in the housekeeping and laundry departments, dietary staff, or in whatever way they see fit.  All of these cuts affect the residents and have a possibility of leading to some type of abuse. 

            Many facilities are also under-staffed due to many different reasons, which contributes to the reasons of elder abuse.  While nursing homes must met certain staffing requirement hours each day, for example South Dakota has a 2.5 hours per resident per day requirement, some facilities may choose to cut its budget narrowly in this area leaving the employees that are working feeling the pressure and therefore itself and its residents more susceptible to and the conditions ripe for abuse. 

            Another reason for the under-staffing in nursing facilities is the high turn over rate.  Some facilities have as high as a 100% turn over rate.[19]  The high turn over rates may be contributed to several different factors including being over worked, under paid, and under trained.   Taking care of the elder and their needs is hard work, which is why many people choose to place their loved ones in a nursing home facility.  Their work includes providing daily care needs, transferring the residents, and providing for hygiene needs just to mention a few of the employee’s duties.  For many this is overwhelming and they feel over worked.  When this is combined with the low amount of pay provided for the employees it may provide for unbearable working conditions.  Upon talking to a director of nursing within a nursing home she stated she believes that the low amount of pay provided, about $7.27 an hour in South Dakota, is a huge contributing factor to the high turn over rates that occur in nursing homes.  Many employees also feel and possibly are under trained.  If an employee feels thrown into a positions with such high responsibility and liability without sufficient training in medical, emotional, and psychological needs of nursing home residents the pressure may cause to be too much and the employee may be deficient at job performance or may just choose to end the employment with the nursing facility.  Whether it be the under-financing of the facility, the under payment or under training of the employee or the over worked feeling of the employee that leads to the high turn over rate is unsure but one thing that is for sure is that the conditions and probability of elder abuse occurring in the nursing facility become more prevailing when the facility is under staffed.   

            And the final reason for the occurrence of abuse in nursing homes, which will be discussed in this article, is the use of physical restraints.  “Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’ body.”[20]  As stated above the NHRA sets the regulations for the use of restraints.  In addition to these stated requirements the NHRA calls for an assessment of problematic behaviors, physician concurrence prior to the institution of restraints, use of restraints only as a last resort, and explaining the restraints and why it’s being used on the resident and then getting the residents consent.  Although the use of restraints is regulated by the NHRA the practice of their use has become seriously discouraged however 85% of nursing home residents will be subject to a restraint at some time.[21]

            The reason for the discouragement of restraints is due to their minimal protection and their cause of serious injury.  Studies have reported that they promote rather than hinder injuries.  Risks related to restrains are well documented with at least 200 Americans dying each year in restraints.  One to two residents die yearly by strangulation from their restraints. [22]  Other types of injuries indicated by studies are skin tears, abrasions, cuts, burns, falls, chronic constipation, and worsening the balance abnormalities.  Restraints also threaten personal autonomy and dignity of the resident and cause feelings of isolation, fear, humiliation, anger, and confusion.[23] 

Used appropriately and in appropriate situations restraints may be useful but studies have proved that the use of restraints is far outweighed by the dangers that accompany them. Studies confirm that when restraints are removed minor injuries increase modestly while serious injuries significantly decline among residents.[24] Restraints may be the wrong size, inappropriate for the resident, the incorrect device, applied incorrectly or monitored inadequately that can contribute and lead to situations of abuse.[25]

The reasons for elder abuse in nursing homes vary from situation to situation and are not easily determined.  Because determining the reasoning behind the abuse is extremely difficult it is important to look to what is being done and what can be done when situations of abuse do occur.

VII.     WHAT TO DO WHEN ABUSE IS DETECTED & WHAT HAPPENS AFTER IT IS REPORTED

The NHRA grants residents of nursing homes the right to be free from abuse but it does not address the issue of what is to be done if abuse does occur or is suspected.  The NHRA does state that it “shall not be construed as limiting such other remedies, including any remedy available to an individual at common law.”[26]  This leaves open the remedies that the state chooses to apply for nursing home residents.  Since the federal government has chosen not to govern what happens after abuse it is up to the particular state, at least for the most part, to provide for remedies and actions when nursing home abuse is reported. 

The NHRA also provides residents with the right of access to a state ombudsman.  As described earlier this provides for a third party to investigate complaints made.  In 1995 the ombudsman annual report reported that of the complaints to the ombudsman’s over 85% of them came from nursing homes. The ombudsman report contains all complaints and not just ones of abuse reported by residents and their loved ones.  But of the 82,442 complaints pertaining to nursing homes 24,587 involved the residents’ rights and of this 6,128 were for abuse, gross neglect and exploitation.[27] Although the federal government regulates nursing homes by providing for an ombudsman and surveying nursing facilities on a regular basis through NHRA this is as far as it goes and the rest of the regulations are for each state to provide. 

A director of nursing in South Dakota gave an example of state legislation providing for the regulation of abuse in nursing homes.  South Dakota is a mandatory reporting state requiring that all complaints be written, an investigation done, and then the resolution/problem solving that was initiated in order to better the facility and discontinue the behavior complained of.  As to the specific complaint of abuse South Dakota requires that the facility notify the state within 48 hours of the report.  It also requires that the resident’s next of kin be informed and a full investigation of the report and a resolution of how to deal with the behavior named in the report be complete with in 72 hours of the reported abuse.  This is just one example of how a state may chose to deal with the horrific problem of elder abuse in a nursing home facility. 

What to do about suspected or known abuse may be unclear since the guidelines are not clearly laid out for the victim and they vary from state to state.  Every state has an ombudsman available to receive and investigate complaints and every state also has legislation in place to for the guidelines to follow when abuse is suspected in nursing facilities.  Because of the unclear guidelines the best thing to do when abuse is suspected is to look to the state laws and regulations on nursing homes and procedures to be followed. 

Elder abuse is a very sensitive subject with regulations and guidelines in place that are just as sensitive, which leads to remedies that are difficult to find and hard to achieve.   When reports of abuse have been found to be true there are many different options the victim may turn to but these options are not always easily found or accomplished due to the many novel circumstances occurring in nursing homes and their surroundings.   Some of the possible causes of actions and remedies available are denial of payment of federal funds, civil penalties, appointment of temporary management at the facility, suits under false claims act, false advertising, breach of contract and breach of resident’s rights, tort and criminal liability.  Although there seems to be plenty of options for the abused elder resident there are several reasons why these are not pursued, some of which will be discussed below. 

One reason an elder abuse remedy is not pursued has already been mentioned- that is that residents and/or their loved ones are afraid of what will happen to the resident if the facility knows that abuse has been reported.  The elder person has to maintain a residence there and may feel threatened that abuse will become worse or he/she will be treated poorly in the many areas of care that the facility provides for the resident.  Because of the fear of being treated even worse the resident may choose to continue to endure the abuse instead of reporting it to the appropriate officials. 

Another obvious reason that an elder resident may not purse a remedy for abuse is that the resident is not aware of his/her remedies.  These residents are older and did not grow up in the era of lawsuits and may be unaware that the law can remedy elder abuse.  But even if the resident is aware of his/her remedies he/she may be unaware of how to retrieve them or believe that an attorney is unaffordable.  Nursing home residents may suffer from dementia or other types of diseases that prevent them from remembering or seriously inhibit their credibility.  These are some of the reasons that abuse may go unreported but when the resident does choose to report it and go forward with the investigation process the civil and criminal causes of actions available may prove to be unsatisfying. 

Most states’ have criminal statutes specifically targeting the abuser who is a “caregiver” under a contractual duty or under a “legal” duty to provide care.[28]  Although the statutes give the resident a feeling of security in that the abuser will not be able abuse another resident or even the same resident again they do little to readdress the specific instance reported.  The abuse has already occurred and though the abuser may be given a fine and/or imprisoned the harm has already occurred thus leaving the resident to confront the after effects. 

Civil remedies have also been implemented in many states.  Through these remedies the abused resident may be given money damages for the suffering he/she has endured but this carries with it two problems.  First the elderly resident may not be mentally aware of the injuries and thus unable to testify as to how the abuse has affected him/her.  Second the traditional measures of damages may be unavailable to the resident because of his/her limited life expectancy.[29]  Civil remedies bring the possibility for the resident to collect monetary damages for the abuse experienced but the mental, psychological, and emotional effects still linger.

It is impossible to change the past and the effects of abuse will exist no matter what remedy the law provides.   But by providing a reachable remedy by law it is more likely that the resident will feel some type of relief.  Because it is impossible to change the effects of abuse it is important to regulate and stop the abuse before it happens. 

VIII.    RISK MANAGEMENT FOR ELDER ABUSE IN NURSING HOMES

Elder abuse in nursing homes is a delicate subject to approach.  Because identifying abuse and the reasons for it are uncertain the solutions to it are difficult if not impossible to come by.  Though there is no absolute way of preventing abuse that occurs in nursing homes some precautionary devices for risk management may be set in place in order to limit the abuse that does occur. 

The first suggestion as to risk management for abuse in nursing homes is to put into effect federal criminal statutes that apply to all nursing homes.  This would make residents aware of a remedy and it would apply to all nursing homes receiving federal funds therefore consistency would be achieved.  The states would still be able to provide for tighter regulations but the minimal consequence for abusing the elderly residents in nursing homes would be clear.  Federal criminalization of the abuse would also announce that it is socially unacceptable thus providing a deterrent effect.  It would also provide deterrent in that the stigma of being criminally convicted as opposed to being held civilly liable is greater.  Putting into effect a federal criminal statute prohibiting and conferring a consequence for elder abuse in nursing homes would provide for all nursing facilities to be charged under one act while at the same time having a deterrent effect by announcing that it is socially unacceptable.[30]

The second suggestion for risk management is for the nursing home to articulate its philosophy and maintain a policy regarding methods of protecting residents form abuse.[31]  This policy should provide the nursing homes standard of care, how it should be done, and what process to follow if abuse is detected.  This policy should also provide for the particular procedures as to restraints and when and how they will be used.  By providing the nursing home policy up front the resident will know what to expect and employees will know what is expected of them and the consequences of inappropriate behavior therefore providing a deterrent effect for the employee. 

The third suggestion for risk management in nursing homes is extensive education at all levels of nursing homes.  Nursing homes need to provide education to all employees of the facility especially to those who provide hands on care to the residents in order to ensure that the employee knows how to effectively deal with situations of all kinds.  Education also needs to be provided for those employees who do not provide hands on care so that they can appropriately monitor and handle situations that are occurring with in the nursing home.  This education should provide employees with information about how to effectively deal with difficult situations and how to appropriately manage and complete daily duties.  Areas of education may include: reviewing categories of residents at risk for restraints, training on behavioral approaches, addressing proper use of restraint devices and alternatives, reminding of the importance of resident quality of life, live demonstrations in the proper use of restraints, role playing or experiential activities, reviewing content of policies and procedures, reinforcing facility philosophy regarding restraint use, watching videos on restraint and abuse issues, and highlighting legal liability associated with restraints and abuse.[32]  By providing staff with education as to their duties and alternatives available they will be more aware of what is expected of them and the liability imposed upon them therefore there will be less chance of elder abuse in the nursing home. 

            And the final suggestion for risk management in nursing homes is for the state to clearly recognize and enforce standards of care with in them.  The state should provide for legislation that encompasses, among other things, a private action against a caretaker for violating the residents right to be free from abuse, mandatory reporting requirements, minimum damages recoverable, attorney’s fees, and encouraging legal enforcement of the residents rights.[33]  By states providing for this type of legislation nursing homes, its employees and its residents will be more likely to take laws prohibiting elder abuse in nursing homes more seriously and therefore deter abuse that might otherwise occur. 

            Although right now it seems to be an impossible task to completely prevent elder abuse occurring in nursing homes implementing some risk management skills with in the nursing homes will assure that the abuse will be limited.  By implementing risk management skills, beginning with the above mentioned, federal and state governments along with nursing homes can begin to prevent elder abuse that is presently occurring. 

X.                 CONCLUSION

Through all of the requirements and guidelines already provided by the federal and state government and through the individual nursing homes policies it would seem as though the issue of elderly abuse would be seriously limited.  But as in any other instance individuals and companies do not always follow the law and/or negligently or willfully violate it therefore elder abuse remains a prevalent issue within the nursing home setting. 

As mentioned at the beginning of this article not all nursing homes abuse their residents or have employees who do so.  Because nursing homes are similar to any other facility one nursing facility may be more appropriate for an individual resident than another nursing facility will be.  Making the decision to place oneself or a loved one in a nursing home facility may be one of the most difficult and important decisions to make and the issue of abuse adds to the stress and anxiety that accompanies this decision.  Through research and interviewing qualified and caring nursing home staff members I have combined a checklist of some basic things to look for and to do when considering placement in a nursing home facility in order to make a somewhat informed decision.  This checklist includes:

1)  The appearance of the facility- is it decorated and looking homey in order to give a feeling of ease to the resident?

2)   The cleanliness of the facility- is it clean?  Do the residents and employees look clean?  Is there any unusual odor?

3)   The interactions between the employees and the residents- are there interactions between them?  If so what is the nature of them?

4)   The greeting you receive when you enter the facility- are you ignored or acknowledged?  A visitor should always be asked if he/she can be helped.  The more this is asked the better. 

5)   Medicare/Medicaid skilled- “skilled nursing”- is the facility complying with federal requirements?

6)   Licensure through the state- this is a must but asking about it will never hurt.

7)   Size and cost of the facility- the more expensive is not always the best and the cheapest may be that way for a reason.  Depending on the individuals needs is the size appropriate for the person?

8)   Ask to see the nursing facilities own policy handling abuse- does the person know this procedure and is the policy well accessible?

9)   Talking to other resident or families of residents- are they happy?  What do they think of they facility and employees?

10)  Ask for a list of activities, including community activities, the residents are able to participate in- are they on grounds or off grounds?  Will they accommodate the residents’ ability?

Though this checklist is not all encompassing it provides simple guidelines a person can easily look to in order to put his/her mind more at ease and feel secure in placing a loved one in a nursing home facility.   Because there is no guarantee against elder abuse occurring in nursing homes it is important that the resident, where possible, and the family of the resident remain involved on a daily basis and demand the quality of care the elder person deserves.