Identifying Elder Abuse

This is the Nursing Home Abuse Podcast. This show examines the latest legal topics and news facing families whose loved ones have been injured in a nursing home. It is hosted by lawyers Rob Schenk and Schenk Firm of Schenk Smith LLC, a personal injury law firm based in Atlanta, Georgia. Welcome to the show.

Schenk: Hey out there and thanks for joining us again. My name’s Rob Schenk.

Smith: And as always, I’m Schenk Firm.

Schenk: And we are trial lawyers practicing in the area of nursing home abuse and neglect law in the state of Georgia. You have stumbled upon the Nursing Home Abuse Podcast. This is a video podcast, meaning you have different ways to consume it. You can either watch it at our website, NursingHomeAbusePodcast.com, or on YouTube, or you can download the audio version of this on Stitcher or iTunes Radio every Monday morning. So welcome to the show.

Here’s something. Again, this is something that we see a lot in the news, we see a lot with our clients coming to us or potential clients coming to us, and they over and over again, they want to know what are the various signs of physical abuse or neglect with their loved ones in long-term care facilities, and what’s interesting about this is that in October of 2016, an article came out, which cited a study of emergency room visits that found a formal diagnosis of elder abuse is made in only one in 7,700 emergency department visits in the United States.

One in 7,700 cases of elder abuse are made in that many visits – in other words, individuals including the ER physicians, nurses, staff are unable to identify the signs of abuse and neglect.

Smith: And this is something that puts it even more into context – 23 million emergency department visits by older adults annually, and one in nine older adults experience some form of abuse. So think about that – 23 million are visiting the emergency departments in the U.S. One in nine are being exploited or abused, and yet only one in almost 8,000 is actually discovered.

Schenk: That’s so low that it’s sad.

Smith: It’s a travesty. It’s a national emergency is what it is.

Schenk: So you have individuals that are professionals in providing emergency care and not being able to identify these signs and investigate the cause of these injuries. So what can we do to identify signs of abuse in our elders?

Smith: You know, the very first thing that needs to be done, and here’s one of the reasons that this happens so often, and it is not a commentary on anybody specifically that has family in nursing homes, but I have seen it way too often, and it is a horrible thing to see, is that a lot of nursing home residents are simply dropped off in nursing homes and their family never visit or they visit maybe once a year on Christmas or Thanksgiving. And while the staff should be vigilant and taking care of, it’s something the staff that are abusing.

And understand something here – we’re talking about specifically elder abuse, not neglect, not failing to do something. We’re talking about, specifically here, intentionally doing something to these elderly patients.

So the very first thing you can do is be involved in their life. If you have a loved one in a nursing home, check on them and check on them often. The more you’re involved in their life, the more you’re going to notice the signs and symptoms of elder abuse.

Schenk: Exactly. Exactly. And that is from one standpoint just you’re able to prevent it because you’re there and you see it when it first starts, but another thing is that staff and studies bear this out – nursing home staff, long-term care facility staff are less likely to mistreat, intentionally mistreat residents whose family members are actively involved, and that’s because they don’t want to get caught.

Smith: One hundred percent, like in the nursing homes we worked at, we always knew – and it’s a shame that some people get a little bit extra attention – but we always knew which family members were the most involved, because higher management would make sure that – and I’m making these names up – “Hey guys, I want you to go and I want you to give special attention to Mr. James’s room today and I want you to clean it up because the family might be coming soon.” They were scared of any possible litigation or just any complaints. The squeaky wheel gets the grease, so go up there and get involved in their lives.

Schenk: Another thing to look out for is any type of drastic change in the behavior of your loved ones. So for example, if you loved one is normally gregarious, outgoing, even in loved ones who may not be the same as they were 10 or 15 years ago in terms of mental capacity, but generally smiling or laughing, but you find over the course of days or even weeks that they’re more and more withdrawn – that is an indication that something is happening, and I’m not saying in every case it’s abuse, but that is a sign, or at least in our cases where there has been physical abuse that we’ve uncovered, that was one of the first things that triggered our clients to come and talk to us is that their grandmother or grandfather, whoever it is, is shying away from us or they don’t want to leave their room.

Particularly in cases where there is physical abuse from a staff member, sometimes, particularly in residents that are unable to, they don’t have the capacity, they might not be able to verbalize that this particular person is doing something to me, but they will definitely not be wanting to be around them.

Smith: Yeah, it’s the same way if you have small children, 2-3 years old. They can’t necessarily carry a conversation with you and say, “Hey, this is what’s going on,” but you notice a change in their behavior.

Schenk: Exactly. So changes in behavior – they’re withdrawn or maybe they’re more prone to be agitated. Maybe they’re very quick to get angry with you when you come to visit when that would normally be out of character for them. So again, a change in behavior, a change in attitude. There’s also, you may want to consider if you observe drastic changes in appetite, drastic changes in sleep patterns. So these are symptoms of withdrawal. Sometimes abuse leads to depression and that in turn leads to loss of appetite or maybe even inability to sleep. That’s something to pay attention to, that type of tertiary signs.

Smith: And clearly bruising, abrasions, cuts – and you have to take into account the elderly – and this is one of the reason why bedsores are so common – the elderly, their skin integrity is less. The elasticity has changed from when they were younger. They tear easily. They bruise easily. Their bones break easily. So that doesn’t mean that if you see a bruise on your mother or your father, and it may even seem really bad because when they do bruise, they’re sometimes really horrible bruises simply because they’re older and the bruise spreads more, but still, be on the lookout. Does that happen often?

Schenk: And so you’re more likely to catch the symptoms if you’re involved more often in the life of your loved one. So if you’re going every six months, you might not be able to see a change in behavior. You might not be able to notice, “Was that bruise there the last time I was there. Where is the location of the bruise?” – that type of thing. So being involved I think is one of the number one things.

I think that – and we’ve mentioned this in previous podcasts – something that you might want to do is you want to not only visit often and be involved, but ask questions of the staff. Interact with the staff.

Smith: Absolutely.

Schenk: Get to know Nancy the charge nurse, that kind of thing.

Smith: And how do the staff behave to you? You’ve got to understand that one of the reasons that abuse happens, and people always ask, “How could somebody possibly hurt an elderly resident?” It is a highly emotional and physically draining job working at a nursing home. So you’ve got individuals who are pushed to the physical and emotional limits working anywhere between seven to 12 to 16-hour shifts. And sometimes some people just break down.

So take note of how they act around you. Are they courteous despite being tired and exhausted? Do they seem courteous to the other residents? Those are big deals. They could be early warning signs.

Schenk: Exactly. So those are some of the things to look out for. You have – are there changes in behavior? Are there changes in weight, sleep pattern, attitude? Are there literal physical signs – bruising, cuts, abrasions, fractures – that are unexplained, that have no explanation?

Getting to know the staff, being there as often as you can, those are things too that will help you prevent those things from happening, but from a standpoint of those are the signs of physical abuse to a resident of a facility… No one sets out to abuse somebody. Why does this happen so often?

Smith: First, there are a couple of avenues that the abuse can come from. You’ve got to think that if you’ve got a loved one, let’s say your mother’s in a nursing home, you need to be concerned about abuse coming from the staff, coming from other residents and also coming from other family members that you may have. I’ve certainly seen situations where husbands would abuse their wives and then leave, and then the family member didn’t know what was going on. Sometimes husbands and wives are put together in the same facility and one can be abusive to the other. Obviously residents can be abusive to each other.

But as far as staff is concerned, you know, the problem here and I just touched on it briefly a few minutes ago, this is one of the most emotionally and physically draining jobs there is. People often ask me, “What’s the hardest thing you’ve ever done?” And you’ve got to understand, I was in the Marine Corps. I definitely consider being a CNA in a nursing home, as strange as this sounds, I consider it more challenging and difficult in many aspects, simply because you’re dealing with individuals who can’t take care of themselves, who can’t move themselves.

You’re constantly picking them up and moving them around. They can’t control their bowel functions and so you’re being urinated on, defecated on in an hourly basis sometimes. You have residents who don’t understand what’s going on and they’ll try to scratch you. They’ll try to bite you. You have family members who – and please, always be nice to the staff – I’ve had family members complain to me and my CNAs because mother doesn’t have any ice right now. Well you know lady, we’re understaffed. You know where the ice bin is. Go get your mom some ice.

And so you’ve got to understand that it takes a tremendous temperament and bearing to do this job. It takes a certain kind of person. When nursing homes don’t weed out the people who can’t handle it, and when they don’t provide enough staff to make sure that these individuals, who are just human, just human, provide enough staff to make sure these individuals don’t reach a breaking point, abuse can happen.

I will tell you that in eight years as a CNA, I can thankfully say I never witnessed, nothing that I recall, I never witnessed abuse. It doesn’t mean that it didn’t happen at the places I was involved in. I never witnessed it. I would have certainly informed the authorities immediately, but I have seen the videos that we’ve all seen on CNN or Dateline of somebody snapping and punching an elderly.

Schenk: It’s not necessarily that this is a bad apple. I think to your point is that sometimes you have an average person who has an average threshold of pain that when over the course of the day, you might have been bitten, you might have been peed on, and when somebody yells and tries to hit you, even if they’re not fully there, that can cause something in you…

Smith: …To snap.

Schenk: You might snap and you might hit back, and that’s never right ever.

Smith: Absolutely.

Schenk: Ever. But that’s the circumstance in which we live. We have bad apples doing bad things but then we have regular apples, so to speak, that reach a breaking point because the job is difficult and it’s made more difficult when you don’t have enough help.

Smith: And that’s another thing to look out for in being proactive against elder abuse is go on those nursing home compare websites for CMS and look at the staffing reports.

Schenk: And that’s actually a good segway into my next question for you. So those are the signs and symptoms of elder abuse. We talked about why it occurs. How can we tell someone how to find a good nursing home where there is less of a likelihood that their loved one will be abused. How do you find out of the thousands of places you can go, how do you choose those? You have experience with that. What do you look for?

Smith: You know, and it may seem like with the job that we do and the topics that we have in our podcast that there are no good nursing homes out there. That’s not the case. I have worked at some nursing homes where the residents were clean, they were well-fed, they were happy, it was well-staffed, the staff was paid well – places that I would put my loved one.

And so the very first thing you need to do is you need to, when you do your reconnaissance, you need to physically go to that nursing home. Do not simply read from the website what the reviews are. That’s a good place to start, but it’s only a place to start.

Schenk: So when you go to the facility, why is that important? What is somebody looking at when they physically go?

Smith: What do you see and what do you smell and what do you hear? To be honest with you, when you walk in, and this is important – it’s basic and it may seem a little crude, but many nursing home residents are incontinent. Many elderly are incontinent. And so they should be changed very frequently. When you walk in, does it smell like feces? Does it smell like urine? I have walked into some nursing homes and immediately was hit with the overpowering smell of either urine or feces. That means that something’s been sitting there for a lot longer than it should. That is a sign of neglect.

Schenk: And not necessarily saying that if it smells badly that it’s…

Smith: No, because you’re going to have that. If you go by… Anybody who’s had babies know that you walk by your baby’s crib, you can tell when they need to be changed because there’s an odor.

Schenk: So from the opposite viewpoint, what would a good smell be like?

Smith: It should smell clean. It should smell favorable, like linen, not heavily industrial. I don’t like that because I think that tends to hide smells, the overpowering smell of bleach or something neutral.

Schenk: So that’s the smell test, I guess. What else are we looking for? What are we trying to observe?

Smith: Then I guess the next one would be sight. Look around. How does this building look? Does it look like it’s falling apart? Are there holes in the wall? Do the floors look clean? Do you see the residents? Do you see residents out? Do you see them doing activities? What does the staff look like? Are they presentable? Are they smiling?

Schenk: What does a typical – and you can go by each position – but what does a typical nursing home staff member wear? Like what would acceptable or normal?

Smith: They’re all wearing scrubs.

Schenk: So scrubs would be what you look for.

Smith: Scrubs, yeah, they’re all wearing scrubs. You know, the CNAs are wearing scrubs. The physical therapists are wearing scrubs. The floor nurses are wearing scrubs. The charge nurse typically wears scrubs though not always. And then the administrator is going to be the person who’s in business attire, whoever he or she may be. The social worker is probably going to be in some sort of informal business attire as well.

But yeah, so look around. What does the place look like, first and foremost – do people look happy? Then the next thing would be to listen. It is an unfortunate aspect of nursing homes that you have individuals that don’t know what’s… They have dementia. They have Alzheimer’s. They have other mental issues and you may hear screaming. And you may hear somebody who is screaming constantly. Unfortunately there is not a lot you can do. You can’t give these people chemical restraints just to calm them down. A lot of times they are given things, haloperidol or other anti-psychotics, but that may not be a sign of neglect necessarily, but it may just mean this is not the nursing home you want to put your loved one. So listen.

Schenk: Would you recommend, if after doing a physical observation, before you place your loved one in a location, to spend at least a significant amount of time, maybe a few hours, watching say a meal being distributed?

Smith: One hundred percent. Number one, what does the food look like? That’s so important. Are people eating it? How are they feeding people? Are people getting their meals in time?

Schenk: How important is it to observe how many staff members per resident during the meal?

Smith: It’s extremely important. You will see – and this is something you need to keep in mind whether it’s hygiene, whether it’s activities and daily living or whether it’s meal assistance – no nursing home has a 1-to-1 ratio staff to resident.

Schenk: Impossible.

Smith: It’s impossible. The cost would be just astronomical. But it should be reasonable. I mean I can easily feed two residents at the same time. To be honest with you, sometimes we even do a little bit more than that, maybe three. But it shouldn’t be one person in a dining room full of residents trying to make them all finish their meals.

Schenk: Because that would also be impossible.

Smith: That’s impossible as well. I mean that’s going to take two hours. By then the food’s cold. Somebody is going to get neglected.

Schenk: So in other words, mealtime is a good indicator of the care they will receive any other part of the day, so that’s a very good practice to go and observe mealtime.

Smith: You know, another thing you can do is talk to the other family members. “I’m thinking about putting Mother in this nursing home. Can you tell me your thoughts on it?” And they’ll be more than happy to tell you what their experience is.

Schenk: So aside from physically observing, going down and doing the smell test, observing what’s going on or perhaps sitting in on some type of activity, whether it’s a recreational activity or mealtime, another important component to researching the correct nursing home for your loved one, I find, is actually doing online research, not necessarily on the website or Yelp or something like that, but actually researching the Medicare website. And you’re researching the Medicare website for previous citations for deficiencies.

So for example, if Medicare has investigated that facility for improperly passing out medication or failing to respond to a fall or even things, as Will mentioned, with regards to the upkeep of the building – we’ve seen nursing homes while investigating them for one thing have seen that they have been cited for not having a proper locking mechanism on the doors or fire alarms being outdated or not functioning. So there are things like that. So if you see a nursing home or a long-term care facility has been cited for multiple things, that might be an indicator that that’s not a very well run operation and you may want to avoid that location.

So these are just a couple of things you can do. It’s just be vigilant – do a gut test. Do you get a good feeling? Do you get a good vibe from the place when you go and talk to them? At the end of the day, this is a service you’re paying for and you want to get value for that, and if you’re getting treated like garbage, then you need to let your money do the talking.

Smith: Absolutely.

Schenk: But at the end of the day, these are the things that are going to make it less likely – it’s not going to eliminate the risk of abuse, but it helps reduce that risk.

Smith: Or neglect in this case.

Schenk: Or neglect. Exactly. So these are some of the things to look out for. We’ve come into the last segment of our episode today. This is actually a particularly gruesome story in the news. This actually again comes from our neighbors to the north, which usually I thought were more passive neighbors.

Smith: Canada’s having some issues.

Schenk: Yeah, Canada is definitely…

Smith: I don’t suggest people keep moving there despite the election results.

Schenk: Exactly. So we have here – hold onto your seats, hold onto whatever you have in Canada, but Elizabeth Tracey May Wetloafer, a registered nurse in Woodstock, has allegedly killed eight nursing home residents in Ontario. The deaths span between August 2007 and August 2014. Police would not say how they died except that seven were administered a fatal dose of a drug. The age of the victims were from 75 to 96.

This is probably one of the worst things that I’ve ever heard in terms of nursing home abuse, I mean this is obviously a serial killer that preyed on residents of this particular facility. That’s amazing to me. So would you going and observing a long-term care facility probably identify the potential for a serial killer? I doubt it. I think this is just such an outlier of an outlier situation, that’s why we wanted to talk about it, that this is such a sad situation.

Smith: This is the segment where we talk about strange news that is very rare and uncommon. Like I just told you earlier, in my eight years, I never personally witnessed abuse. It’s rare, and even rarer still would be a situation like this. But what I find especially troubling for Canada is that the study cites that 4 to 5 percent of seniors in Canada experience some form of abuse. That’s a much higher percentage than we have here in the US and I thought that was a little strange. I don’t know why I thought Canadians would be kinder to the elderly than their southern neighbors, but they’re clearly not. We were talking one in nine – they’re much higher than that and that’s troubling.

Schenk: Okay, so let’s say that you’re running a nursing home and you have let’s say the seventh death. I mean…

Smith: I mean at some point, when does it become the nursing home’s responsibility?

Schenk: Yeah. Exactly.

Smith: There’s a smell test here that you guys are not passing. But this also brings up another issue for me, and this is something that we’re just happy to get the regulations that we have to help the nursing home residents now.

Something that I think would be very helpful and I’d like to see it in the future is not only a background check, but actually a psychological test for nursing home workers to see if – not just rooting out the serial killers – but can you handle this type of job?

Schenk: I mean I think that’s pretty far off because that’s an expensive endeavor.

Smith: Oh yeah, I mean we’re doing…

Schenk: Or maybe somebody can come up with some type of Myers-Briggs, like at least get 5 percent of potential applicants weeded out through just a simple administration of a test.

Smith: Yeah, but you know, this situation again where you’ve got somebody murdering these individuals, this is one in a million. It really is. This doesn’t happen that often.

Schenk: And on that unusual note, we will unusually sign off of this video podcast. I think that’s all we have for this episode. Again, you’ve been listening to the Nursing Home Abuse Podcast. This is a video podcast, so you can as always watch this, watch Will and I talk every week either on our website, which is NursingHomeAbusePodcast.com, or on YouTube, or you can listen to the audio version either on Stitcher or on iTunes, and you can be sure to subscribe, leave a review. We would really love that. We would really appreciate that and we will see you next time.

Smith: Have a great Monday!

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