OASIS Alert

Here's how to spot abuse and neglect in patients' homes.

If you think most instances of elder abuse takes place in nursing homes, your patients could be in trouble. Fact: Most elderly patients are neglected or abused right in their own homes, according to the American Psychological Association. And that puts you on the front line of preventing and reporting abuse -- just by following the OASIS assessment.

Besides the obvious human suffering, abuse or neglect can keep your patient from following the plan of care, achieving the expected outcomes and being cared for successfully at home. Here's what you can do to protect your elderly patients:

Patients needing home care are often vulnerable to mistreatment by their caregivers and family members. The count of older persons abused, neglected or exploited reaches hundreds of thousands each year -- two-thirds of them by family members -- according to the Department of Health & Human Services'

Reality: For every reported case of elder abuse or neglect, there are probably five that are not reported, the APA predicts. Clinicians providing home care have the best opportunity to assess both the patient and the home environment -- even if doing so feels disloyal or like snooping.

Your comprehensive assessment, including the OASIS questions, addresses many aspects of a patient's physical and emotional condition that offer a glimpse into the patient's life when the clinician is not there. For example, M1700 (Cognitive functioning) checks the patient's ability to follow commands and looks for disorientation and delirium. M1740 (Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week) and M1745 (Frequency of disruptive behavior symptoms) can uncover a patient's physical or verbal aggression, socially inappropriate behavior and other problems that may be stressing the caregiver.

Warning: Risk of abuse and neglect increase when the patient is physically aggressive, refuses to eat or take  medicine, is noisy, invades the caregiver's privacy, exhibits disruptive behavior or embarrassing public displays or has what the caregiver considers "vulgar habits," reports the National Center on Elder Abuse (NCEA) in Washington, DC.

Bonus: Besides looking at stresses on the caregiver, M1740 can detect signs of abuse in patients, such as impaired decision-making. M1720 (When anxious) helps you evaluate the level of anxiety and M1730 (Depression screening) addresses the patient's mental state. These are important clues to abuse and neglect.

You should also pay attention to patients present at each visit. "A person who is being neglected or abused may show increasing indicators of cognitive problems, including daily decision-making, mood and anxiety," says Gail Robison, a registered nurse and consultant with Boyer and Associates in Brookfield, Wis.

Heads up: If the patient needs assistance with eating and you see significant weight loss, there could be "some measure of neglect" or the caregiver may "lack knowledge about how best to provide feeding assistance," notes Barbara Bates-Jensen, a nursing professor at the UCLA School of Nursing and the VA GLA Geriatric Research Education Clinical Center.

Pay Close Attention To Skin Assessment

Answering "yes" on M1300 (Pressure ulcer assessment) should trigger an evaluation of possible causes of this problem, experts agree. Remember that one cause can be caregiver neglect of the patient's medical needs and hygiene, the NCEA points out on its website.M1306 (Does this patient have at least one unhealed pressure ulcer...?) may seem like a frustratingly inclusive question. As defined by the Centers for Medicare & Medicaid Services, almost everyone has some kind of skin lesion. But if you note bruises or skin tears, you need to look further.

Obvious causes: "Someone taking Coumadin is more likely to bruise with minimal trauma," Bates-Jensen says. Elevated prothrombin times or chemotherapy-induced anemia can also increase chances of bruising, she adds.

Dialysis patients have more fragile skin and are more likely to get skin tears and bruising, Robinson notes. And osteoporosis can result in unexplained fractures. "Twisting motions, such as pivoting in a transfer, can cause fractures in severely osteoporotic individuals," says St. Louis, MO-based physician Charles Crecelius.

Don't stop there: Look closely for a pattern of fractures that may indicate rough handling or abuse, Robison says. Look at abrasions, bruises, burns and skin tears, she advises. Skin tears do occur in someone with fragile skin. But if skin tears suddenly pop up -- or if there's an erratic pattern where they are noted on one assessment but not others -- take a closer look. It could be an assessment accuracy issue or it could be due to abuse or rough handling, she suggests.

Resources: The NCEA site contains extensive resources about elder abuse at www.ncea.aoa.gov.

Obtain a list of signs and examples of elder abuse and neglect from the APA at www.apa.org/pi/aging/cona/index.aspx. To locate help in your state, call 1-800-677-1116.