Kelly Riddle defines the types of elder abuse and neglect he’s seen in his years investigating claims.
This article was adapted from Riddle’s book, Nursing Home Abuse Investigations. He has also published a CE course on this topic for PI Education.
Getting old is not for the faint of heart.
Losing physical and mental capacities is frustrating, disorienting, and can even be terrifying. After a long life of hard work and raising a family, finding oneself suddenly dependent on other people — or even on strangers — can produce feelings of helplessness, insecurity, and isolation.
It can also make older people vulnerable to misuse or exploitation. Many are physically weak and defenseless. Some have suffered strokes or dementia and lost motor skills or cognitive ability. When a patient cannot speak or resist, they become an easy target for abuse.
First, let’s define what we mean by the term.
What is elder abuse?
According to a violence prevention site at CDC.gov, elder abuse is “an intentional act, or failure to act,” by a caregiver or trusted party, which causes harm to an older person or puts them at risk. Abuse can take the form of physical violence, neglect, sexual abuse, emotional or psychological cruelty, or financial exploitation.
To reiterate: Abuse is intentional behavior. Let’s face it, accidents happen to everyone, in every job. Abuse is not an “accident.” Usually, it’s a pattern of willful actions and an indicator of some variety of ill intent. Unfortunately, some people are miserable human beings, and they take this out on everyone around them. The elderly are an easy target.
In my years of investigating cases of abuse in nursing homes, I’ve seen some categories crop up again and again:
Verbal Abuse and Humiliation
One of the more common types of abuse in eldercare facilities is verbal abuse by staffers: employees screaming at patients, calling them insulting names, or making degrading remarks about their appearance or their inability to control bodily functions.
Some facility directors find it easier to just overlook verbal abuse by staffers because, “Hey, at least they showed up for work!” Or they might just pass it off as the person’s having a bad day. This says something very sad about how low the bar often is for quality of employees at some of these centers.
Verbal or Psychological Threats and Manipulation
When employees say they’re going to spank patients who keep wetting the bed, this is what I mean by a verbal threat. These patients most likely can’t control their bladders, which makes such ultimatums particularly cruel — and also utterly pointless. Another common type of threatening verbal abuse is when employees tell patients to eat or else they will shove food down their throats.
There are proper ways to let a person know what you want them to do. This is not one of them.
Other threats are less overt. Staffers might restrict access to visitors, certain foods, activities, or resources like telephones or money. Older patients crave connection and attention, like we all do. Threatening a person with isolation is one way an ill-intentioned caregiver might manipulate patients into overlooking wrongdoing.
When caregivers abuse their power over vulnerable patients, it’s psychological abuse, and it can cause significant mental anguish. Nobody wants to imagine their parents being treated this way.
Neglect
Failing to meet patients’ basic needs or to protect them from harm is a depressingly common problem in care facilities, which are often understaffed and under-resourced. Many times, one aide will be responsible for 6-60 patients by themselves, a workload far beyond what is reasonable or even humanly possible. An acceptable ration in the industry would be more like 6-10 patients per aide.
Plenty of nursing home employees are diligent professionals who care about their patients, but as we know all too well, some are not. The nursing home industry attracts many low-skilled, minimum wage workers. I’ve seen many instances where employees were found asleep on duty or watching TV in patients’ rooms.
Some kinds of neglect occur when patients who need help walking have to wait hours before being helped to the restroom. Employees may delay feeding patients or administering medications, or forget these tasks entirely. In one case we investigated, employees moved call buttons out of reach of bedridden patients so they wouldn’t “bother” the staff. One of these patients broke her hip trying to make it to the bathroom.
Other types of neglect are even more egregious. A common source of problems in understaffed nursing homes is when staffers fail to keep up with routine daily or weekly tasks — and falsify charts to indicate otherwise. I had a client in one case who died of malnutrition. The charts reflected that the staff weighed the patient regularly. One week the chart might have her weight as 90 lbs., and the next she’d be down to 70lbs — a physical impossibility. Upon further investigation, employees stated that they seldom, if ever, actually weighed the patients; they simply guessed the weights and wrote them on the chart.
In another malnutrition wrongful death case, we found that employees were eating food that was meant for patients.
Another common issue caused by neglect is bedsores that go septic. When caregivers fail to turn bedridden patients frequently, or when patients are left lying in their own urine, they may develop bedsores (pressure ulcers), which are painful and very slow to heal. If left untreated, bedsores can become infected. In one of my cases, a woman died from complications of bedsore infections. Once again, the charts reflected that she was getting bathed, turned, and treated regularly. It turned out that the employees who initialed the charts were not even on duty on the days she supposedly received all of this care.
The employees who initialed the charts were not even on duty on the days she supposedly received all of this care.
Dropping or mishandling a patient are fairly routine occurrences, and they can cause serious, even life-threatening injuries to older adults with brittle bones and fragile skin. Some are accidents, of course, but some are acts of negligence. In both categories, the worst harm is often done when employees try to cover up the error.
I had one client whose leg was broken when staffers dropped her as they were rotating her. Instead of taking her to the hospital, the employees put a makeshift splint on the leg. One of the aides later told me that a co-worker had been fired for turning the patient roughly, causing her significant pain and harm to the broken leg.
There is a fine line between neglect and abuse. Sometimes neglect can become so flagrant, pervasive, or harmful, that it reaches the point of abuse. I’d say that several of the examples above bear that out.
Physical Abuse
The sad fact is that virtually any kind of abuse you can imagine can and does happen to older people in long-term care homes. It’s likely that most of these incidents go unreported. Some common cases we see involve senseless, daily coercion, such as staffers grabbing patients’ cheeks to force feed them or pinching and yanking on patients to make them move faster.
Some instances are so bizarre as to defy belief. In one case where a client had broken her hip, we learned that a staff member “slam dunked” the patient into bed by throwing her out of the wheelchair and into the bed.
Others are simply tragic and unimaginable. At one facility we looked into, we had reason to believe that a nurse had suffocated a patient with a pillow. The death was never investigated, and the nurse was terminated two weeks later for being intoxicated on the job.
Sexual Abuse
It’s not uncommon for romantic relationships to develop in nursing homes, as they would in any co-ed setting. Visiting spouses may also continue sexual relationships with a partner who has moved into extended care. Problems arise when patients have health problems that cause the intercourse to be painful. I had one very fragile female client who had tubes and IVs sticking out all over her. Her husband would come by, push the roommate into the hall, and have sexual intercourse with his wife. Several employees testified that she could be heard screaming, moaning, and crying because of the pain. The staff was told to not intervene.
In cases like that one, or when patients have dementia or cognitive decline, there are difficult questions of consent to consider. Many nursing home employees choose not to address those question at all and simply pretend nothing is happening.
There are also predators who target patients who are frail, nonverbal, and and unable to defend themselves. These attacks may come from staffers, other patients, family members, or strangers from off the street. Often, employees are too busy to notice unusual signs, or they may be afraid to speak up.
Final Thoughts
As long as the long-term care industry fails to adequately police itself, families will keep filing lawsuits against offending facilities, and juries will continue handing out large awards. My take is that this is an industry-wide problem, caused by facility owners whose main priority is squeezing every penny of profit from the operation. In their quest for profit, owners often pay their staff slightly above minimum wage. LVNs and RNs receive a lower pay than their counterparts at hospitals, with predictable damage to attitudes and morale.
Fortunately, there are still conscientious professionals willing to step forward and tell the truth about the abuse and neglect they have witnessed at work. In our investigations, we find that many of these whistleblowers have worked at all of the nursing homes in the area, hoping to find one that isn’t as bad as the one they just left.
One day, I hope, long-term care centers will learn a simple business principle: It’s better to pay up front to hire high-quality professionals, and plenty of them, instead of shelling out cash on the back end for the lawsuits that WILL arise when tragedies occur due to understaffing, poor training, and low morale. But until the industry figures this out, there will be plenty of work for investigators like me, who are hired to investigate on one side or the other of an abuse or neglect claim.
Also, in the next couple of years I expect there’ll be countless investigations of nursing homes in the wake of COVID-19 — questions about high infection and mortality rates, and what, if anything, facilities could have done to prevent these tragedies. Sorting out who did their best in a desperate situation and who failed catastrophically in their duty to these patients will likely occupy U.S. courts for years to come.
About the author:
Kelly Riddle is the president of Kelmar Global Investigations and has more than 39 years of investigative experience, specializing in surveillance, insurance investigations, nursing home abuse, and computer investigations. Riddle is the author of ten books and a popular public speaker who frequently appears on local and national media. His prior law enforcement experience includes being a member of the SWAT team, an Emergency Medical Technician, evidence technician, and arson investigator. He is the founder and president of the PI Institute of Education, as well as the Association of Christian Investigators, with more than 1500 members worldwide.
