by Kelly Riddle, KelMar
& Associates
San Antonio, TX

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.
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.
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.
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 they crave.
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.
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 a bone.
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.
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.
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.
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 them.
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 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 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.
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.
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 presenting itself.
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 the doors.
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.
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 general investigations.
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 kelmar@stic.net.