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Long-Term Care Survey Alert

Resident Assessment:

Keep Resident Sexual Abuse on the Radar Screen

Published on Thu Feb 16, 2012

These symptoms require evaluation, says forensic nurse specialist.

Sexual abuse in nursing facilities "is more common than people think," said Lisa Tripp, a former HHS attorney, during a CMS webinar, "Sexual Abuse in Long-Term Care." Tripp also expressed concern that "surveyors may be missing it -- and facilities may be getting this issue wrong as well."

Linda Ledray, RN, PhS, SANE-A, FAAN, tells Eli that physical signs of abuse "appear in 40 to 50 percent of adults over age 60 but in only 30 percent of younger people." Physical signs of sexual abuse include the following, according to Ledray:

  • Bladder infection. Recurrent UTIs in a person who hasn't previously had them would potentially be more suspicious, says Ledray, director of the Sexual Assault Resource Service in Minneapolis, Minn.
  • Genital bruising or bruising around the thighs. The latter "could indicate that the thighs were forced open," Ledray explains.
  • Vaginal discharge. This "could be a sign of a sexually transmitted disease and should be evaluated," advises Ledray. "The standard of care is to culture" the vaginal discharge, adds Dianne Ditmer, PhD, RN, CFN, DABFN, SANE, FACFE, with the Kettering Medical Center in Dayton, Ohio.
  • Genital or rectal bleeding. "A lot of times staff will attribute genital bleeding to the woman scratching herself" in the perineal area --r in the case of a male, to hemorrhoids, Ledray observes. "But unless the woman has an infection, which you'd want to evaluate as well, you should look into the reason for the genital or rectal bleeding," Ledray counsels. "Staff should look into complaints of anal pain, which could be a sign of molestation."

Tips: "In the nursing facility, doing a head to toe assessment at admission for pressure ulcers is a good time to look for signs of abuse," advises Ditmer. "Incorporating an assessment into routine bathing is a perfect time to look for signs of abuse, neglect, and non-violence related health issues," Ditmer adds.

  • Behavioral signs: Nursing facility staff should also "pay attention to any change in a person's behavior," says Ledray. "Don't just attribute it to old age or dementia. Examples include situations where the person suddenly starts resisting a bath, especially when a certain caregiver is doing the care."

The resident "may be more cranky, which is a sign of depression, or if the abuse is occurring in their room, they may not want to be in the room -- or they may seem fearful at night, if the abuse is happening then," adds Ledray.

Ask Residents, Family Members About Abuse

Ditmer reports that her community has a coroner's office committee that "does death reviews and links those back to whether the deceased person was ever in the hospital to make sure they were screened" for potential abuse. "When we have identified people who weren't screened, the nurses say it embarrassed them to ask the person if anyone has been hurting or touching them inappropriately," she says. Yet "it's important to keep asking because a person may take time to tell you that they are being hurt --ou have to develop a relationship," Ditmer stresses.

Kenneth Daily, LHNA, believes that that "all facilities, regardless of what survey process is used in their state, can and should be asking [residents] the three basic resident abuse questions from the Quality Indicator Survey (QIS) Resident interview," which are as follows:

  1. "Have you ever been treated roughly by staff?
  2. Has staff yelled or been rude to you?
  3. Do you ever feel afraid because of the way you or some other resident is treated?"

"The questions are seen as an opportunity to establish trust with the resident by asking questions that do not force them to reveal too much upon meeting a stranger (surveyor)," says Daily, president of Elder Care Systems Group in Dayton, Ohio. But "if surveyors listen carefully and follow-up on any 'yes' answer," they can "discover inappropriate treatment of residents."

Daily says staff should also ask family members the QIS family interview questions about abuse, as follows:

  1. "Have you ever noticed any staff member being rough with, talking in a demeaning way or yelling at [resident's name] or any other resident?
  2. Did you report it? (If 'No,' ask the relative/friend if he/she knew how to report the concern. If his/her response is 'No,' initiate the Abuse care area for the resident and the Abuse Prohibition task for the facility.)
  3. Did facility staff act promptly to investigate and correct the situation?"

Resources: The complete resident and family interviews, respectively, are available at www.qtso.com/download/qis/forms/CMS-20050_ResidentInterviewAndObservation_revised.pdf and www.qtso.com/download/qis/forms/CMS-20049_FamilyInterview.pdf.

You can watch the CMS webinar on sexual abuse at www.cmstraining.info/pubs/VideoInformation.aspx?cid=1092.

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