Long-Term Care Survey Alert

These key strategies will help protect residents and your facility.

Rethink the unthinkable: Families become abusive with residents "more often than we'd like to admit," says Kathy Hurst, JD, RN, director of health care operations for TSW Management Company in Anaheim, CA, which owns and manages nursing facilities in California.

You don't want to second-guess yourself after the fact, wondering if you missed the signs that a family member posed a threat to a resident. A few guiding rules can help you identify families at risk for abusing their loved one, which allows you to provide extra oversight and support.

For example, "prior violence predicts future violence," cautions forensic nurse Daniel Sheridan, RN, PhD, FAAN, a nursing professor at Johns Hopkins University. "You can identify a violent history through a family assessment," he says. Patients may also tell you about incidents of violence in the family, advises Sheridan.

Other risk factors include a family with a history of known alcohol and drug use/abuse -- and those with unrealistic expectations of the resident's abilities, adds Sheridan. The family members may also be impatient with the resident, he adds.

Sheridan notes there's sometimes a fine line between family members talking to a resident with "an exasperated tone born of desperation and fatigue versus yelling." But if staff hears a conversation between resident and family "fraught with frustration," that's a red flag to assess and intervene -- and offer the family member some support, says Sheridan.

Hurst notes that if a family member verbally abuses or yells at a resident while in the facility, staff generally tells the person to leave and counsels the person that if it happens again, the facility will ban the person from visiting or allow them to visit only upon appointment with supervision in an open area of the facility, she relays.

Sheridan advises facilities to consider implementing a policy in which every resident receives a discreet head-to-toe nursing assessment to identify any marks on the person's body before he leaves the facility.

"You don't want to single out families for such a policy," he says. "Just let families know the facility is committed to an abuse-free environment and they assess everyone before they leave the facility for any reason."

Sheridan notes that the policy can prevent abuse because the family member is forewarned he will get caught if he harms or neglects the resident. "And the family is more likely to report a fall or other incident resulting in bruising or injury."
Look for, Document Signs of Abuse, Rough Handling

"You may see fingertip bruising on the inside of the resident's legs which occurred when a caregiver cleaned the person too roughly after an incontinent episode," Sheridan cautions. Or you might see bruising under the arms indicating the resident slid out of a chair and the family member pulled him up too roughly. "That reflects impatience where a caregiver is forcing the person along," says Sheridan. If a family member hit a resident, you might see "obvious defense bruising" on the resident's forearms that wasn't there before the resident departed with a family member.

An insidious sign of purposeful abuse: Someone who wants to control another person may pull her hair, says Sheridan. "Staff may see evidence of this when the resident returns to the facility" -- for example, clumps of hair on the person's pillow almost as if the person has had chemo but you know she hasn't," he says. Or you may see a lot of hair in a brush when you brush it.

How you'll know: The hairs will have the root attached, says Sheridan. And if you assess the scalp, you will find points of tenderness. "The nurse or other assessor can draw a body map and mark the tender areas on the scalp," advises Sheridan.

Do an investigation: If the resident returns from a visit with bruises or abrasions, "the staff should do a thorough investigation, including interviewing family members to see if they saw anything, like a fall," advises Patricia Boyer, RN, principal of Boyer and Associates in Brookfield, WI. (For key advice on meeting federal and state reporting obligations when you suspect a family has abused a resident, see the next Long-Term Care Survey Alert.)