Respecting and Protecting Elders

By Elliott A. Boxerbaum, CPP, and Patrick F. Donaldson

Those within. Crimes at LTC facilities are not limited to those perpetrated by trespassers or burglars. Staff may also pose threats, especially as a resident’s vulnerability increases and he or she becomes more dependent on caregivers. Elements to consider when assessing threats within an LTC environment include current employee recruitment processes, screening and background checks, and supervision of employees.

In some communities, the demand for entry-level resident care and custodial workers is high. Staff turnover in these jobs is also high, and some organizations have chosen to reduce costs by cutting back on reference checks that provide vitally important information about potential employees. These organizations run the risk of both increased security incidents and increased resultant liability costs. Negative publicity could also taint the reputation of the facility.

Additionally, the facility’s incident reporting policies and procedures should be reviewed, as well as resident property tracking and management, and the training and regular reevaluation of both the security and care staff. Internal security audits should also be studied.

Another concern is the threat that residents may pose to one another. For example, more than 400 registered sex offenders were LTC residents, according to a 2004 study, “Predators in America’s Nursing Homes, Registered Sex Offenders Residing in Nursing Homes Analysis,” conducted by A Perfect Cause, a disability and elder-rights advocacy organization.

The study identified one 144-bed skilled-care and intermediate-care facility in Ohio as the residence of 15 registered sex offenders—more than half of whom were convicted rapists. A Missouri nursing home mentioned in the study was reportedly the home of 12 sexual offenders. The study also cited multiple cases of offenders committing assaults and rapes in the facilities where they were housed.

Because of these incidents, LTC providers and advocacy groups debate whether a facility has a responsibility to notify residents and their families when residents who may pose a threat—especially registered sex offenders—are admitted.

One way to address the risk of patient-on-patient crime is a patient-background screening program similar to employee preemployment screening. Checking the backgrounds of residents can be controversial, however.

If patient background checks are conducted, the intent should not be to reject a resident, but rather to provide the facility with information that it may need to ensure the safety of that resident, other residents, visitors, and staff. Confidentiality of information, communication of adverse information, and other related issues need to be addressed in well-constructed policies and procedures. Certain types of background checks may require a signed release by the resident or disclosure of the results by the requesting organization. Policies such as this should be reviewed by legal counsel prior to implementation.

Danger to themselves. Many LTC residents are not a risk to others, but to themselves. Among the largest risks to this group are slips and falls and other injuries. However, two additional significant risk issues are wandering and running away from the facility.

Many LTC residents suffer from Alzheimer’s disease, dementia, disorientation, and other neurological impairments, placing them at high risk once they leave the care environment. While these wandering residents may not be trying to flee the facility, others do actively try to leave.

Both types of wanderers have ended up injured or dead. According to insurance company studies, the primary causes of death in these cases were being struck by a vehicle, overexposure to heat or cold, drowning, or traumatic injury resulting from physical or sexual abuse that occurs outside the facility.

The assessment of programs to reduce the risk for wandering and elopement should include a review of building and unit design, and pedestrian and vehicular circulation patterns.

At one facility, wandering was curtailed without limiting residents’ access to the outside by the creation of a fully fenced and beautifully landscaped courtyard with twisting walkways, fountains, benches, and an arbor. There is no access from or to this garden via public streets or neighboring roadways. Closed circuit television cameras are used to assist staff in monitoring the area.

The use of wandering-patient tracking technologies should be evaluated, as well as other elopement-prevention strategies and response planning and training, including coordination with local police, fire, and emergency medical service officials.

The assessment should probe whether there is timely and adequate communication with the site’s neighbors when a patient has gone missing. At one facility, for instance, photographs of residents known to be at risk are maintained by security and are available for distribution to local authorities and search teams.

The response plan at this facility includes emergency packets, which are provided to staff who are searching for the missing resident. The packets contain maps depicting the immediate area, recommended search patterns, and zones of responsibility for employees. It also identifies likely destinations of wanderers, such as area grocery stores or libraries, and known hazards.

Each search team is equipped with a cell phone or radio for communication. A command center is established to manage the entire process and coordinate ongoing efforts.

Response plans should ensure that family members get the information and support they will need. In addition, a media plan is important. Often, media will learn about the incident as soon as the police are notified. The absence of a clear communications process can lead to disastrous public relations outcomes.

As with all other emergency plans, drills should be conducted on a routine basis. All staff members should be trained in their responsibilities, and this training should be documented. Issues identified during drills or as a result of an actual incident should be addressed. Plans and training should be updated accordingly.

In the aftermath of an incident, there should be a mechanism for assessing causative factors and for the development and implementation of a corrective plan. 



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