Stacy L. Donnelly, RN, BSN, Nursing & Nursing Home Expert
Neglect is defined as a caregiver’s failure to provide or meet a person’s basic needs such as food, clothing, shelter, proper hygiene, and medical care. Failing to ensure these needs are being met, increases a person’s risk for infections, illness, deterioration and compromising safety. Neglect is often associated with a caregiver, but can also refer to self-neglect. Self-neglect is when a person is unable or willing to provide or maintain care for themselves.
Facility based programs have the responsibility to ensure an appropriate level of care is provided to their residents which includes providing interventions for individuals who can no longer care for themselves. It is the responsibility of the facility to provide care and assistance to ensure that the individual’s basic needs are being met.
A person may no longer choose or be able to care for themselves, it is still important for them to maintain a high level of participation, dignity, and be ensured their basic needs are being met. A person’s physical health affects their mental health and vice versa. For example, a person experiencing depression is likely to experience unwanted weight gain or weight loss, just as someone with medical ailments is at a greater risk for depression. For a person living in a facility, it is the role of the facility to assist in maintaining their sense of pride, worth and respect.
Under federal regulations §483.24 Quality of Life, “Each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being” Facilities must create and sustain an environment that humanizes and promotes each resident’s well-being and feeling of self-worth and self-esteem.
A facility has an important role in maintaining the health, safety and well-being, of its residents. This is done through ensuring a person is receiving adequate food to meet their nutritional needs, assisting, and providing appropriate clothing, providing a safe environment in which to live, ensuring consistent and reasonable hygiene, and providing or coordinating medical care.
A person may have limited ability to make appropriate decisions related to the types of food required to support their nutritional needs, have difficulty chewing or swallowing, or lack the ability to feed himself/herself. When this occurs, they will require assistance from a caregiver and dietician to assure they are recieving proper nutrition. Proper nutrition is important in maintaining a person’s physical and mental health.
Long term care facilities are required under federal regulation §483.60 Food and Nutrition Services, to “provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.” The facility is also required to provide residents with assistance in eating, special eating utensils and adaptive equipment to best meet their needs.
Warning signs that a person is not receiving proper food and nutrition may include unusual and unplanned weight loss, dehydration, falls, pressure ulcers, sudden change in mental status, and uncontrolled diabetes.
A person residing in a long-term care facility may have difficultly moving, stretching, bending, and twisting. They may also have difficulty choosing or obtaining their clothing. The person may need to be provided with items such as adaptive clothing. Adaptive clothing can enhance the person ability to self-dress and decrease the possibility of injury by making clothing easier to manage.
Under federal regulation 483.10(a) Resident Rights (interpretative guidelines), the facility should encourage and assist “residents to dress in their own clothes appropriate to the time of day and individual preferences.” A person residing in a facility should have seasonally and environmentally appropriate clothing.
Warning signs that a person is not receiving proper assistance with their clothing may include wearing shorts and short sleeved shirts or going outside without a jacket when it is cold, tattered, stained or ill-fitting clothing. In addition, a person should not remain in night clothing or hospital gowns for the convenience of the caregiver. Their clothing should not have labels that are visible externally.
Persons not having or being provided appropriate shelter can lead to serious health risks and increases their risk for harm. Some health risks include infections, acute illness, chronic illness, and death.
Long-term care facilities are required under federal regulation §483.90 Physical Environment to maintain an appropriate physical environment for residents. These requirements include meeting Life Safety Codes and providing rooms that are “designed and equipped for adequate nursing care, comfort, and privacy of residents.” They must also “provide a safe, functional, sanitary, and comfortable environment for the residents.”
Warning signs a facility is not maintain a proper environment are resident rooms and common areas being unclean, residents complaining showers are cold, and clutter throughout the facility.
Poor hygiene of a person may be an indicator of a more serious issue. They may have underlying medical issues such as Alzheimer/dementia, physical disability or medical ailments preventing them from maintaining good hygiene. A lack of proper hygiene may not only lead to medical issues but also decreases a person’s feelings of self-respect, pride and self-worth.
Under federal regulation §483.20 Resident Assessment, when a person’s care needs change due to either behavioral or medical changes, the facility is required to assess and implement appropriate care interventions to best meet the needs of the resident. Those persons residing within a facility should receive the necessary care to maintain appropriate grooming and hygiene.
Warning signs that a facility is not providing proper hygiene assistance my include a person having a foul body odor, appear greasy or dirty, have unkempt hair, dirty and ragged clothing, tooth loss and decay, frequent infections, and pressure ulcers.
Providing the person with appropriate medical care is essential in assisting them to maintain a good quality of life. The most minor of health issues can quickly become serious if left untreated.
Residents of long-term care facilities have the right under federal regulation §483.30 Physician Services to have access and be seen by a physician. The regulation states, “The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter and the facility must provide or arrange for the provision of physician services 24 hours a day, in case of an emergency.” Medical care that may be offered includes physician services, dental care, ophthalmology, mental health, and specialty medical care.
Warning signs that a facility is not providing appropriate medical care and follow-up include a person experiencing issues such as non-age-related deterioration of health, frequent hospitalizations, and unexplained and unplanned weight loss, frequent infections, pressure ulcers, and depression.
Facility Investigations of Allegations of Neglect
Under federal regulation §483.12 Freedom from Abuse, Neglect, and Exploitation, a facility must have evidence that all allegations are thoroughly investigated, and the results of the investigation must be reported to the administrator and to other officials in accordance with State law within five working days of the incident. A facility may be alerted to a possible problem or suspicion of neglect by a variety of sources; the direct care givers, ancillary staff, family, friends, visitors, and most importantly, through direct observation of their residents. Once there has been an allegation of neglect, an internal investigation is initiated immediately. An investigation is a process through which the facility gathers facts related to the incident. An investigation may take different forms depending upon the circumstances of the case but typically, it begins with a review of the reported incident. During the fact gathering process, the person(s) conducting the investigation may want to review the staffing records to identify the staff assigned to the resident and ancillary staff in the facility during the time frame. They may want to engage in a process of interviewing and obtaining written statements from any staff that had possible contact with the resident, ancillary staff on duty, the alleged victim, possible witnesses, or the person making the report. A full review of the alleged victim’s medical record should be conducted. Once all facts have been gathered, the data is analyzed and evaluated. At the conclusion of the investigation, the facility will determine if the evidence supports the allegation of neglect.
It is important for a person to maintain a positive sense of pride, self-worth, and be treated with respect in order to preserve their optimal psychological and physical well-being. If they are no longer able or willing to meet their basic needs of food, clothing, shelter, proper hygiene and medical care, they may require the assistance of caregivers in a facility. It is the obligation of the facility to promote and enhance a resident’s quality of life and implement preventative measures to avoid situations where neglect can occur.
Stacy L. Donnelly, RN, BSN, Nursing & Nursing Home Expert with DJS Associates, Inc., can be reached via email at experts@forensicDJS.com or via phone at 215-659-2010.