Identifying and Reporting Elder Abuse within a Facility. Attorney Maren Beermann Guardianship Support Center Coalition of Wisconsin Aging Groups

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1 Identifying and Reporting Elder Abuse within a Facility Attorney Maren Beermann Guardianship Support Center Coalition of Wisconsin Aging Groups

2 Types of Abuse Self-Neglect Financial Exploitation Neglect by Other(s) Verbal/Emotional Abuse Physical Abuse Sexual Abuse Treatment without Consent Unreasonable Confinement/Restraint

3 Risk Factors in Facilities Low staff-to-patient ratio Poorly trained staff, especially with residents who are physically dependent High turnover of staff Cut corners due to lack of financial resources

4 Risk Factors in Facilities High percentage of residents with dementia Isolation No advocate or family to check in regularly Mobility or sensory (deaf/blind) limitations Language barriers/cultural differences

5 How to Identify Abuse in Facilities Physical injuries (bruises, broken bones, sprains, dislocation, broken eyeglasses or frames, welts/burns) Especially suspicious if injuries occur symmetrically on two sides of the body or continues to occur repeatedly in the same area Care provider refuses to allow you to see the resident alone and the resident is heavily clothed/covered

6 How to Identify Abuse in Facilities Sudden and unexplained change in weight Malnutrition or dehydration Dry mouth Sunken eyes, cracked lips, dark colored urine, chills, ashen skin skin turgor test note, turgor does decrease with age!) Complaints of meals (review nutrition plan)

7 How to Identify Abuse in Facilities Falls and accidents Repeated Loss of hair Bedsores Soiling, poor hygiene, smell of urine/feces Inappropriate clothing for setting Infections Unexplained venereal disease or bleeding

8 How to Identify Abuse in Facilities Frequent arguments/tension between care provider and resident Serious Behavioral Changes: Anxiety/depression/fear/passive/ submissive Rocking, sucking, mumbling Listlessness/unresponsiveness Infantile or other strange behavior

9 How to Identify Abuse in Facilities Wandering, repetitive movements Distressed behavior Physical aggression Confusion, inability to express needs Unexpected visitors during normal visiting hours are denied visitation or delayed access

10 How to Identify Abuse in Facilities Hoarding Restricted visitation by substitute decision-maker not medically founded Missing property Residents forced to conform to arbitrary facility schedule/practices (meals, bathing, exercise, etc.)

11 How to Identify Abuse in Facilities Not providing healthcare but charging for it Double-billing/overcharging Kickbacks for prescribing certain drugs Recommending fraudulent remedies, unnecessary treatments

12 In Depth: Financial Exploitation THE SIGNS: Money management changes in account balances, spending habits (even the $45 MMMNA!) account activity missed bills, unusual bills, more bills People around elder with unusual behavior, level of care, concern, or knowledge about the elder taking actions that isolate the elder

13 Legal documents, including real estate transfers transfers made that the elder does not understand newly executed documents recent or repeated revocations or codicils forged signatures altered documents pre-signed checks or withdrawal slips

14 Elder s environment missing personal property other forms of abuse present: physical, emotional, neglect Elder s behavior fear, shame, hurt, humiliation Covering it up/making excuses/accepting blame

15 Simple Financial Protections Obtain a credit freeze on all accounts Security Freeze Info Obtain free credit reports Opt out of credit marketing lists: OPTOUT ( ) or Opt out of Junk Mail: Register FREE online at egist.action

16 Medication Abuse Overmedication Stolen medication Look at the resident s medications. Does the amount left in the bottle fit with the date of the prescription? (Labels indicate frequency of medication administration)

17 Psychotropic Medications: Chemical Restraints Wis. Stat (6s) and DHS 83.02(41): Psychotropic Medication is a prescription drug used to treat or manage a psychiatric symptom or challenging behavior DHS 83.02(15) Chemical restraint means a psychotropic medication used for discipline or convenience, and not required to treat medical symptoms

18 Food and Drug Administration: unnecessary psychotropic medication administration kills 15,000 nursing home patients per year Inappropriate off-label use Many thousands more suffering injuries One man fell 68 times in four months as a result of inappropriately being placed on a psychotropic medication

19 The Law for a Competent Resident physicians and/or service providers must obtain informed consent before giving a person psychotropic medications To be informed, consent must be: voluntary; based on specific information about benefits, side effects, and alternatives; and provided by a person who is competent to give the consent

20 The Law as Applies to a Guardian 54.25(2)(d)2.ab and ac A guardian may consent to voluntary administration of a psychotropic med only after first making a good-faith attempt to discuss voluntary receipt of the medication with the ward and the ward does not protest.

21 Protest = Need Court Order If the ward protests, the guardian may only consent to involuntary administration of a psychotropic medication under a court order under section

22 The Law as Applies to a POA-HC Agent Consent by POA agent subject to desires of resident as expressed in POA or if resident s desire are unknown, according to Wis. Stats (5)

23 The New Wis. Stat Effective November 25, 2010 Nursing homes must obtain written informed consent before administering a psychotropic medication that contains a boxed warning to any resident who has degenerative brain disorder.

24 The form will include the following: Space for description of benefits of proposed treatment and how it will be administered Description (most current under FDA) of side effects or risks of side effects and any warnings about the medication

25 Spaces for description of alternative medications and probable consequences of not receiving the medication Declaration that the resident or person acting on behalf of the resident has been provided with the information and time to study the information or seek additional information concerning the medication.

26 The Emergency Exception: Is It an Emergency? Meet ALL 3 Requirements: 1. The resident is not subject to court order to administer psychotropic med under 55.14; 2. There is a significant risk of physical or emotional harm to resident or others and time and distance preclude obtaining written informed consent;

27 Is it an Emergency? 3. Physician determines resident or others will be harmed if medication is not administered before informed consent is given

28 In Case of Emergency Oral consent okay Oral consent in resident s medical record Written consent follows within 10 days May administer for 24 hours without oral consent

29 Details Consent may be withdrawn at any time in writing Consent by guardian is still subject to Wis. Stats (2)(d)2.ab and ac Consent valid for the period of time specified on the form with a max of 15 months

30 Abuse Prevention Raise the question: remind guardians about legal limitations surrounding their ability to consent on behalf of the ward Ensure the principal considers psychotropic medications and talks to his/her agent about them when creating a POA-HC

31 What do you do when abuse occurs?

32 Document EVERYTHING. Dates, descriptions, photo if possible Review the care plan, look for discrepancies Talk to the resident if appropriate, regardless of competency Lucid Moments competency is not black and white Involve the family or a friend if appropriate

33 Who Do you Talk To? Talk to the facility about your concerns. Document who you spoke to, when, how long, any response that was given, any actions taken by management Do a bit of research - what are the facility s policies regarding elder abuse/neglect?

34 The Ombudsman Program The ombudsman investigates and resolves problems, provides information, referral and consultation and works with licensing, certification, and other enforcement agencies to improve the quality of care in long term facilities and programs. Nursing Homes, CBRF, residents under the Community Options Program (COP) or Family Care *Outagamie County recently transitioning to Family Care

35 The ombudsman can help with concerns and problems about: the quality of long term care provided; facility residents' rights; personal needs allowance; physical abuse and neglect; dietary needs; financial issues (i.e. billing, government benefits, financial exploitation); physical or chemical restraints; facility transfer and discharge issues; privacy and confidentiality; and denial of community services.

36 Elder/Adult Protective Services (APS) An elder adult or adult at risk has experienced, is currently experiencing, or is at risk of experiencing abuse, neglect, self-neglect, or financial exploitation. Outagamie County:

37 What can APS do? Take intake call; analyze situation Immediately address emergency safety needs to protect from injury and further harm, if possible Investigate need for further evaluation/response Involve other partners if necessary

38 Substantiate that abuse occurred Determine appropriate response/service recommendations Discuss recommendations with abuse victim Implement ongoing preventive measures

39 Division of Quality Assurance (DQA) Responsible for assuring the health, safety, and welfare of residents in facilities regulated by DQA mer/healthcarecomplaints.htm Online complaint intake system file a complaint

40 Department of Regulation and Licensing To report abuse by a wide variety of licensed professionals including doctors, accountants, funeral directors, nursing home administrators, pharmacists, registered nurses, therapists, etc. Complaint form available online: drl.wi.gov (608)

41 Attorney Abuse Office of Lawyer Regulation to report attorney misconduct (877) Complaint form available online at /public/lawyerreg/file.htm cannot be submitted electronically

42 Medicare/Medicaid Fraud Fraud, waste, or abuse in the Medicare Program Senior Medicare Patrol (SMP) ext

43 Wisconsin Medicaid Fraud Control and Elder Abuse Unit Investigates and prosecutes crimes committed against vulnerable adults in nursing homes and other facilities, as well as fraud perpetrated by providers against the Wisconsin Medicaid program. MFCU: to file a complaint Part of the Wisconsin Dept. of Justice

44 MCFU Investigations Medicaid provider fraud Abuse of, neglect of and misappropriation from residents or patients residing in facilities that receive Medicaid funds; Abuse and neglect of residents in board and care facilities that do not receive Medicaid funding, such as nursing homes, CBRFs, and adult family homes; Criminal laws affecting the Medicaid program (i.e. fraud and the health, safety and welfare of Medicaid recipients).

45 Law Enforcement Outagamie County Sheriff s Department: (920) (non-emergency)

46 Coalition of Wisconsin Aging Groups Guardianship Support Center ext. 314 Elder Financial Empowerment Project ext. 328

47 Civil Remedies Nursing Home Litigation continues to rise (but not limited to just nursing homes!) - if the resident can afford to hire an attorney Petition to review guardian/agent s conduct failure to fulfill basic duties and base neglect/ignorance of the law and duties is common

48 Questions? Attorney Maren Beermann Guardianship Support Center ext. 314 COALITION OF WISCONSIN AGING GROUPS This presentation was supported, in part, by a grant (Number 90AM3183/01) from the Administration on Aging, U.S. Department of Health and Human Services (DHHS). Grantees carrying out projects under government sponsorship are encouraged to express freely their findings and conclusions. Therefore, points of view or opinions of the author do not necessarily represent official Administration on Aging or DHHS policy.