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Family Members’ Reports of Abuse
in Michigan Nursing Homes
Abstract
The objective of this paper is to describe abuse and neglect of adults aged 65 and older in
Michigan nursing homes, as reported by members of their families. Using list-assisted random
digit dialing, data on abuse and neglect for a 12-month period were collected from individuals
who had a relative aged 65 or older in a Michigan nursing home. Of the nursing home residents
represented in this analysis, the majority were female, Caucasian and widowed. Neglect and
psychological abuse were the most frequent types of abuse reported. Comparisons of these data
with data from the National Ombudsman Reporting System suggest that family members
constitute a sensitive source of data on abuse in nursing homes.
Family Members’ Reports of Abuse in Michigan Nursing Homes
Nursing home care represents a frequently chosen option for long-term care in the United
States. Health United States 2005 reported that the number of nursing homes in the United States
was 16,323 in 2003, with 1,756,699 nursing home beds. In Michigan the number of nursing
homes was 431 in 2003 with 49,226 beds (NCHS, 2005).
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Abuse in nursing homes incorporates several types of abuse and neglect, including
physical abuse, psychological abuse, financial abuse, sexual abuse, and neglect. Some forms of
elder abuse can be subtle, such as depersonalizing treatment, labeling and denying opportunities
for personal choice and discriminatory practices.
The dynamics of abuse and neglect in nursing homes are complex. Fulmer, Guadagno,
Dyer and Connolly, (2004) summarize several theoretical approaches to explaining elder abuse
including situational theory, exchange theory, social learning theory, political economic theory,
and psychopathology of the caregiver theory. Each of these theoretical approaches may be useful
in explaining elder abuse in nursing homes, however no single theory is sufficient to account for
the complexity of elder abuse.
Some data suggest that abuse and neglect in nursing homes are not uncommon. A report
prepared for Senator Henry Waxman (D–CA) indicated that during the two-year period following
January 1, 1999, 5,283 U.S. nursing homes were cited for abuse violations, with more than 2,500
of these violations causing harm to elderly residents (USHR, 2001). Based on state ombudsman
data, Allen, Kellett, and Gruman (2003) reported that 47% of nursing homes in Connecticut had
a report of abuse. Jogerst, Daly, Dawson, Peek-Asa and Schmuch (2006) distinguished between
incidents of abuse involving some administrative recognition; reported incidents, and
substantiations after investigation. Their data show that report rates are typically somewhat lower
than incident rates, and that substantiation rates are considerably lower - approximately 25% of
incident rates. Overall, it was found that approximately 90% of abuse events were reported to
state authorities, while 29% were substantiated. Rates also vary with several characteristics of
nursing homes.
The Centers for Medicare and Medicaid Services Automated Survey Processing
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Environment (ASPEN) Complaints/Incidents Tracking System (ACTS) also contains information
on nursing home abuse reports, investigations, and substantiations. These data are available by
year for each state and for the District of Columbia by specific types of abuse. While official data
reporting systems are sources of officially reported abuse and neglect cases, they may not include
a large number of actual cases. It is generally accepted that many cases of elder abuse in nursing
homes are not reported. For example, Peduzzi, Watzlaff, Rohrer et al. (1997) reported estimates
that 60% of the cases of institutional elder abuse in Pennsylvania are not reported. A more
conservative estimate is that only about 1 in 14 incidents of abuse are reported (Pillemer &
Finkelhor, 1988). Surveys of employees in nursing homes most assuredly yield underestimates,
since they would be potential perpetrators of abuse and neglect. Surveys of nursing home
residents are likely inaccurate for a number of reasons. For example, some residents would be
unable to respond, others might choose not to report abuse and neglect due to fear of retribution,
and patients with Alzheimer’s and/or dementia might give inaccurate answers. In addition, in a
study of Iowa nursing homes, Jogerst et al. (2006) found that while most events known by
nursing home administrators are officially reported, less than 30% are substantiated by an outside
inspection. Moreover, reported rates are higher in metropolitan versus non-metropolitan areas
(Jogerst et al., 2006).
Official data on complaints about nursing facilities are available from the National
Ombudsman Reporting System (NORS) Administration on Aging (2007). Data from the National
Ombudsman Reporting System (2003) shows that in 2003 there were 19,660 complaints in
nursing facilities in the United States for abuse, gross neglect and exploitation Of these, 5,163
were physical abuse, 962 sexual abuse, 3,618 verbal/mental abuse, 1,048 financial exploitation,
2,775 gross neglect, 5,010 resident-to-resident abuse, and 1,084 other. In Michigan there were 30
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total complaints for abuse, gross neglect and exploitation in nursing facilities. Of these 10 were
physical abuse, 1 sexual abuse, 8 verbal/mental abuse, 4 financial exploitation, 1 gross neglect, 6
resident-to-resident abuse, and no others. While NORS data are collected by ombudsmen in each
state, it is not appropriate to compare incidence of abuse across states. Ombudsmen may not
report all cases of abuse, and a number of factors may influence data collection and reporting
across nursing homes and from context to context (Jogerst, Daly & Hartz, 2005).
In contrast to previous studies, this research uses an alternative approach to obtaining
data on elder abuse and neglect: surveying relatives of residents in nursing homes. This is an
alternative way of determining nursing home abuse prevalence in the absence of reliable
prevalence rates of actual abuse in nursing homes (Jogerst, et al., 2006). While it is possible that
this method may underestimate to some extent actual rates of abuse and neglect, the degree of
underreporting, if any, is not clear. Nor is it entirely clear whether relatives may, at times,
perceive staff actions as abuse when in fact these actions are not abusive. Moreover it is evident
that data collected by personnel and/or residents in nursing homes also could underestimate the
number of cases. A study undertaken by Daly and Jogerst (2005), for example, indicates that
nursing home administrators' and directors of nursing's knowledge of the law and their
characteristics are associated with nursing home incident report, and substantiation of abuse
allegations. Moreover, many administrators lack sufficient knowledge of the law or intentionally
disregard it (Daly & Jogerst, 2005). This is nowhere more true than in Michigan, where an
estimated 70% of physicians are unaware of the state's elder abuse reporting requirements
(O'Brien, 1986). In contrast, in this analysis, we examine the reported abuse and neglect as
perceived and reported by relatives of elderly nursing home residents in Michigan within a
context of officially reported data from the Long-Term Care Ombudsman Program. In the case
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of uncertain data, as in existing reports of nursing home abuse, it is worthwhile to obtain similar
data from an independent source as a means of corroborating the prior data and findings or of
isolating specific issues with the prior data.
Method
Data for this paper are from the Michigan Survey of Households with Family Members
Receiving Long-Term Care Services (MLTCS), a telephone survey of the non-institutionalized
civilian population of adults living in Michigan who have a relative who is receiving long-term
care services (Post, 2006). The term “long-term care services” was defined as any paid service
to assist the family member to do normal daily activities, in either a facility or community
setting. Respondents were selected for the survey by random digit dialing and the 1002 persons
interviewed represent a cross section of households in Michigan with a family member receiving
long-term care services. Family members were the targeted sample as opposed to the persons
receiving the long-term care services because of issues related to 1) accessing a population who
primarily reside in institutions; 2) potential human subjects research violations; and 3)
disabilities that lead to the patient’s receipt of long-term care services, such as dementia or
communication disorders.
The design is cross-sectional with several retrospective sequences. A considerable
number of disability, health, abuse, neglect, and exploitation histories were collected. The cross-
sectional design permits the detailed description of past and current long-term care settings as
well as other characteristics and experiences.
For this analysis, a sub-sample was defined to include adults who reported that a relative
aged 65 or older resided in a facility that they defined as a nursing home. This sub-sample
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included 452 respondents. The variables in the survey that were analyzed here include
demographics and several variables regarding types of abuse and neglect experienced. SPSS for
Windows version 14 was used for this analysis.
Results
Michigan nursing homes contain a relatively homogenous population of largely white
females with no living spouse. Of the nursing home residents represented in this analysis, the
majorities were female (73.2%), Caucasian (91.4%) and widowed (64.8%). In comparison, only
(26.8%) were male while only 8.6% were some race besides White. Of those who were in this
latter category, African Americans comprised (6.4%) with (2.2%) being described as some
“Other race”. In addition, only 22.1% were married; 6.9% were single- never married, and 6.2%
were either divorced or legally separated.
Respondents’ relationships to the person in long-term care were as follows: Spouse 34
(7.5%); Sibling 29 (6.4%); Child 188 (46.6%); Other relatives 40 (8.8%); Parent 2 (.4%);
Grandchild 67 (14.8%); Daughter/Son-in-law 34 (7.5%); Niece/Nephew 31 (6.9%);
Mother/father-in-law 14 (3.1); Self 1 (.2%); Friend 7 (1.5%); Other 4 (8.8%); Refused 1 (.2%).
Asked “How often do you visit this person?”, 449 of the 452 (99.3%) responded. Of those, 342
(76.2%) said they visited once a month or more, and 107 (23.8%) said less than once a month.
Asked “How often do you talk with this person on the phone….?” 402 of 452 (88.9%)
responded. Of these respondents, 126 (31.3%) said they talked once a month or more, and 276
(68.7%) said less than once a month.
Asked “How often do you write letters or email this person…?” 391 of 452 (86.5%)
responded. Of these respondents, 51 (13%) said once a month or more, and 340 (87%) said less
than once a month. Another survey question was “How would you characterize the closeness of
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your relationship with this person? Please give me a number between 1 and 10 that represents the
closeness of your relationship where 1 = emotionally distance and 10 = emotionally close”.
There were 446 valid responses to this question. The mean response level was 8.36 (S.D. = 2.19).
Respondents were asked if the person in the nursing home had experienced several types
of abuse and neglect by staff or other caregivers in the past 12 months. The numbers of valid
respondents were as follows: physical mistreatment 31; caretaking mistreatment 89; verbal
mistreatment 67; emotional or psychological mistreatment 78; neglect 99; sexual misconduct 10,
and material exploitation 64. A total of 23 respondents (74.2% or those responding to the item)
said there was at least one such incident of physical mistreatment by staff or other caregivers
(striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching or burning), and
73 (82% of those responding to the item) reported at least one incident of caretaking
mistreatment by staff or caregivers (over-administration of drugs, withholding or delaying of
drugs, inappropriate use of physical restraints, unjustified force feeding, inappropriate toileting
practices). A total of 56 (83.5% of those responding to the item) reported at least one act of
verbal mistreatment (yelling, cursing or swearing, insults, threats, intimidation, humiliation, or
harassment), and 62 (79.5% of those responding to the item) reported at least one incident of
emotional or psychological mistreatment (treated disrespectfully, disallowing contact with family
or friends, or giving the silent treatment). A total of 86 (86.9% of those responding to the item)
reported at least one incident of neglect (failure to rotate, failure to provide food, water, shelter,
hygiene, medicine, comfort or personal safety). Four (40% of those responding to the item)
reported at least one incident of sexual misconduct (forced sex, sexual contact without consent,
sexual coercion, or unwanted touching), and 46 (71.9% of those responding to the item) reported
at least one incident of material exploitation (misuse of a person’s funds, property or assets, theft
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of money or possessions, or coercion or deception into signing documents or gifting possessions
ever experienced). Numbers of abuse incidents are shown in Table 1.
Insert Table 1 about here
Discussion
As was anticipated, the majority of nursing home residents aged 65 or older in this study
consisted of women, and the proportions of the sample that were widowed and married were not
unexpected.
What is interesting to note is that incidents reported by relatives appears to be
substantially higher than is reflected by official data from the Long-Term Care Ombudsman
Program, which are cases of abuse reported to ombudsmen. In 2003 these data included 30 total
cases of abuse, gross neglect and exploitation of all types including 10 incidents of physical
abuse (33%), 1 sexual abuse (3%), 8 verbal/mental abuse (27%), 4 financial exploitation (14%),
1 gross neglect (3%), 6 resident-to-resident abuse (20%), and no others (National Ombudsman
Reporting System, 2003). According to the MLTCS data used in this analysis, relatives of
nursing home residents were aware of substantially more incidents than were reported to
ombudsmen. It appears that perceptions of abuse among family members are qualitatively
different than reports to ombudsman and that among the latter, “low number of reported
allegations might indicate lack of awareness of what constitutes abusive behavior” (Jogerst et al.,
2006; page 206). This is an important finding since nursing home facilities that report high abuse
incidents are generally thought of as not providing quality care. Our study suggests that family
members may perceive deficiencies in care more often than reported figures would suggest. The
formats of the MLTCS questions are such that direct comparisons cannot be made with the data
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from the Long-Term Care Ombudsman Program. Moreover, it should be noted that the MLTCS
data used in this analysis were collected during the period of October, November, and December,
2005 – two years after the 2003 data reporting year for National Ombudsman Reporting System
data. However, despite these two issues, it appears clear that perceptions of relatives reflect a
higher incidence of abuse in nursing homes than is suggested by National Ombudsman
Reporting System data.
National Ombudsman Reporting System data may suggest that abuse and neglect in
Michigan nursing homes is relatively rare. At the same time, the current findings based on the
MLTCS data suggest that National Ombudsman Reporting System do not include many cases of
which nursing home residents and their families are aware. Indeed, despite concern that the
method of obtaining abuse data from relatives of nursing home residents might underestimate the
actual number of incidents, the findings of the present analysis do not lend support to this
concern.
The value of the awareness of nursing home residents’ family members of abuse has not
escaped the many lawyers whose Web sites offer basic information to relatives about elder abuse
and legal services. A search for “abuse Michigan nursing homes lawyers” yielded about 784,000
hits. Moving beyond Michigan, a search for “abuse nursing homes lawyers” produced about
1,980,000 hits.
The data reported here are best considered in context. Respondents might be wrong in
their assessments of what they know about abuse and neglect in nursing homes, and it is very
difficult to measure the accuracy and reliability of their knowledge. Moreover it is not clear that
any measure of closeness truly substantiates how much the respondents know about abuse and
neglect. Family members might visit frequently while remaining quite unaware of what is going
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on in a nursing home. Others might not call or visit at all, but they might receive information of
abuse incidents from other sources.
It should be noted that Michigan has been believed to be a state with one of the lowest
incidence of abuse in nursing homes (National Ombudsman Reporting System, 2003). Other
states are thought to have much higher levels of abuse. Of course, it goes without saying that any
level of abuse or neglect is unacceptable. It would be of interest to know the extent to which
nursing home residents’ families in other states also are aware of abuse, and how their reports
compare with NORS data.
The problem of elder abuse in nursing homes may increase as large numbers of elderly
individuals require nursing home care. Thus the importance of having sensitive and accurate
measures of actual incidents of nursing home abuse will increase in the future. The MLTCS
survey of relatives fails to corroborate the findings of the NORS data on reported abuse that
abuse rates in Michigan nursing homes are low. This reveals the need for further research to
provide more detailed, accurate and validated data on abuse in nursing homes, and to understand
why relatives perceive but do not report incidents of abuse.
References
Administration on Aging. (2007). National Ombudsman Reporting System 2000-2005 (NORS)
Aging Integrated Database (AGID). Retrieved August 13, 2007 from
http://198.136.163.234/Nors.asp?keep=0.
Allen, P.D., Kellett, K., & Gruman, C. (2003). Elder abuse in Connecticut’s nursing homes.
Journal of Elder Abuse and Neglect, 15(1), 19-42.
Braun, K. L., Suzuki, K. M., Cusick, C. E., & Howard-Carhart, K. (1997). Developing and
testing training materials on elder abuse and neglect for nurse aides. Journal of Elder
Abuse & Neglect, 9(1), 1-15.
Daly, J.M. And Jogerst, G.J. (2005). Association of Knowledge of Adult Protective Services
Legislation with Rates of Reporting Abuse in Iowa Nursing Homes. Journal of the
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American Medical Directors Association, 2(6), pg. 113 – 120.
Fulmer, T., Guadagno, L., Dyer, C. B., & Connolly, M. T. (2004). Progress in elder abuse
screening and assessment instruments. Journal of the American Geriatric Society, 52,
297-304.
Fulmer, T., & Wetle, T. (1986). Elder abuse screening and intervention. Nurse Practitioner,
11(5), 33-38.
Hall, B. L., & Bocksnick, J. G. (1995). Therapeutic recreation for the institutionalized elderly:
Choice or abuse. Journal of Elder Abuse & Neglect, 7(4), 49-60.
Hoban, S., & Kearney, K. (2000). Elder abuse and neglect. American Journal of Nursing, 100,
49-50.
Jogerst, G.J., Daly, J.M., & Hartz, A.J. (2005). Ombudsman program characteristics related to
nursing home abuse reporting. Journal of Gerontological Social Work, 46, 85-98.
Jogerst, G.J, Daly, J.M.,Dawson, J.D., Peek-Asa, C., & Schmuch, G.A. (2006). Iowa nursing
home characteristics associated with reported abuse. Journal of the American Medical
Directors Association, 7, 203-207.
Meddaugh, D. I. (1993). Covert elder abuse in the nursing home. Journal of Elder Abuse &
Neglect, 5(3), 21-23.
Meeks-Sjostrom, D. (2004). A comparison of three measures of elder abuse. Journal of Nursing
Scholarship, 36, 247-250.
Menio, D. A. (1996). Advocating for the rights of vulnerable nursing home residents: Creative
strategies. Journal of Elder Abuse & Neglect, 8(3), 59-72.
NCHS. (2005). Health United States, 2005. Retrieved March 13, 2007 from
www.cdc.gov/nchs/data/hus/hus05.pdf#116
National Ombudsman Reporting System (2003). Data Tables. 2003. Table B-2. Washington, DC:
Administration on Aging. Retrieved August 16, 2007 from
http://www.aoa.gov/prof/aoaprog/elder_rights/LTCombudsman/National_and_State_Data
/2003nors/2003nors_pf.asp
O'Brien, J. (1986) Elder Abuse and the Physician. Michigan Med, 85, pg. 618-620.
Peduzzi, J.J., Watzlaf, V.J.M., Rohrer, W.M., & Rubinstein, E.N. (1997). A survey of nursing
home administrators' and ombudsmen's perception of elderly abuse in Pennsylvania.
Topics in Health Information Management, 18(1), 68-76.
Pillemer, K., & Finkelhor, D. (1988). The prevalence of elder abuse: A random sample survey.
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The Gerontologist, 28, 51-57.
Pillemer, K., & Moore, D. W. (1990). Highlights from a study of abuse of patients in nursing
homes. Journal of Elder Abuse & Neglect, 2(1/2), 5-29.
Post, L. A. (2006). The Design and Content of the Michigan Survey of Households with Family
Members Receiving Long-Term Care Services. The College of Communication Arts and
Sciences. Michigan State University. Retrieved on August 18, 2007.
https://miltcpartnership.org/MainSite/W6.aspx
Reis, M., & Nahmiash, D. (1998). Validation of the indicators of abuse (ioa) screen. The
Gerontologist, 38, 471-480.
Saveman, B., Astrom, S., Bucht, G., & Norber, A. (1999). Elder abuse in residential settings in
Sweden. Journal of Elder Abuse & Neglect, 10(1/2), 43-60.
USHR. (2001). Abuse of residents is a major problem in U.S. nursing homes. In USHR (Ed.):
Minority Staff, Special Investigations Division, Committee on Government Reform.
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Table 1. Number of caretaking incidents of abuse by staff or other care giver in past 12 months
N %
Physical Mistreatment
None 8 25.8
One or two 18 58.1
Three to five 4 12.9
Six to ten 1 3.2
Caretaking Mistreatment
None 16 18
One or two 39 43.8
Three to five 17 19.1
Six to ten 6 6.7
More than ten 11 12.4
Verbal Mistreatment
None 11 16.4
One or two 38 56.7
Three to five 7 10.4
Six to ten 7 10.4
More than ten 4 6
Emotional or Psychological Mistreatment
None 16 20.5
One or two 27 34.6
Three to five 12 15.4
Six to ten 10 12.8
More than ten 13 16.7
Neglect
None 13 13.1
One or two 30 30.3
Three to five 30 30.3
Six to ten 8 8.1
More than ten 18 18.2
Sexual Misconduct
None 6 60
One or two 4 40
Three to five -- --
Six to ten -- --
More than ten -- --
Material Exploitation
None 18 28.1
One or two 30 46.9
Three to five 9 14.1
Six to ten 2 3.1
More than ten 5 7.8