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Long-Term Care Survey Alert

Abuse Investigation:

Detect Injuries That Need To Be Investigated Now Rather Than Too Late

Published on Fri Nov 26, 2004

Hone your forensic wound identification skills to protect residents.

When assessing a resident for abuse, keep in mind that all bruises and fractures are not created equal -  so learn to red flag the type of injuries that need to go on the "stat" track for investigation.

Start by "doing a careful daily skin assessment on all residents and document every little bruise or scratch in a nursing note, so the facility has a paper trail," suggests Daniel Sheridan, PhD, RN, a forensic nurse consultant and professor at Johns Hopkins University School of Nursing.

The next step: Develop a policy that dictates which bruises need a medical or nursing assessment. For example, "an ambulatory resident who does a lot of his own care will end up with little bruises on his elbows, knees, thighs, buttocks - just as everyone does when they bump into something," says Sheridan. That type of bruising may be expected, but other bruises should raise a high index of suspicion. These include:

  • Bruises in various stages of healing in total care patients. "If the resident can move and flayed her arm on the bedrail, you'd expect to see tubular bruising, but not on a part of the body where the person could not have hit the bedrail," offers Sheridan.

  • An unexplained pattern of bruising. "For example, sometimes you can almost see the outline of an object causing blunt trauma," says Sheridan. "And people usually don't bump into something hard enough to leave patterned bruising," he notes. (One nurse discovered a resident had tender areas on her scalp caused by a family member who had hit her in the head with a ring on his finger.)

  • Bruises on the breast, genitalia or the inside of the thighs. These warrant careful investigation for potential sex abuse, says Sheridan (for more information on assessing for sexual abuse or rape in cognitively impaired residents, see "Sexual Abuse", this issue). "Investigate anything that looks like a 'hickey' on the breast, thigh or genitalia," Sheridan urges. "Sexual predators may leave a signature like that to taunt people to figure out what's going on."

    Differentiate Between Bruises and Ecchymosis

    Teach staff and even residents' family members the difference between bruises and ecchymosis, as the latter can appear quite alarming to the uninformed. "Ecchymoses are nonpainful spreading areas of bluish discoloration caused by blood leaking under the skin, although the resident may have suffered very minor trauma to cause it," says Sheridan. By contrast, blunt trauma causes clearer margins of bruising that hurts when pressed, he adds.

    Look for a medical cause to explain ecchymosis. "For example, aspirin and other anticoagulant use (Plavix, Aggrenox, Coumadin and heparin, and even vitamin E) can lead to ecchymosis," as can liver dysfunction and blood cancers, says Chuck Crecelius, MD, CMD, a nursing home medical director and geriatrician in St. Louis, MO. So check the resident's platelets for thrombocytopenia, and his anticoagulation status if he's taking Coumadin or heparin.

    "Investigate instances where the resident prone to developing ecchymoses shows a change in their number or frequency," advises Crecelius. Also be suspicious of ecchymoses that are painful or in unusual locations (they most commonly occur on the arms or legs) or when the resident has a change in condition - or complains of rough handling or has had a recent fall, Crecelius adds.

    Get the Low-Down on Falls

    Don't fall in the trap of simply assuming that elderly people always "just fall" on their own without a little help from someone else. Sometimes that's true, but residents also get pushed down, Sheridan cautions. And don't count on the resident telling you if someone did cause him to fall down. "The person may feel too intimidated to say someone pushed him or hurt him."
     
    Your first move after learning that a resident fell should be to determine who witnessed the fall and get their account(s) of what happened. "Record the witnesses' names in the documentation," advises Sheridan.

    If no one claims to have witnessed the fall, look at the surface that the person fell on. "Does the resident have injuries and debris on her consistent with falling in that spot, such as a wound or abrasion or torn clothing?" Sheridan asks.

    "Large unexplained bruises associated with a fall require investigation," counsels Sheridan. The bruising may be a result of the fall but someone could have hit the person, causing him to fall, or kicked him when he was down.

    Beware These 2 Types of Fractures

    Spiral fractures in elderly people are often related to abuse. "Grabbing or sharp twisting motion tends to cause spiral fractures," says Sheridan. So if a resident gets diagnosed with a spiral fracture, look for a way to explain the twisting and jerking motion, he advises.

    "For example, you might explain a spiral fracture if the resident reached into a washing machine and got his arm twisted into motion (although that's not likely to occur in a nursing facility unless the resident does his own laundry or did it at home during a visit)."

    Transverse fractures tend to occur over a point of impact with some sort of blunt trauma. Thus, look for bruising at the point of impact and try to figure out what caused the blunt trauma.

    "People who raise an arm to defend themselves against a blow     can get a nightstick fracture - a midshaft fracture of the ulna. You will see a bruise at the point of impact on the arm," says Sheridan.

    Consider this: So-called "granny cams" can actually provide a deterrent to abuse and rough handling, even though they raise privacy issues, su    ggests attorney Adam Balick in Wilmington, DE.

    "If staff and visitors know that they are being monitored by cameras, they are going to be less likely to prey on vulnerable residents," he says.

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