Train your staff to keep abuse in check

Are your policies up to date?

It is the kind of case that makes readers cringe. For decades, a disabled woman was abused by her spouse. The warning signs were either ignored or, when reported, lost in the bureaucratic shuffle between social workers and state health department officials. The case, which broke in Washington state in May, has led to calls for changes in policies by the governor, and increased training for state and private health care workers on how to deal with suspected abuse cases. As the population ages, the potential for abuse — physical, verbal, sexual, or financial — among the most needy populations increases. Is your staff properly trained?

According to attorney John Gilliland II, whose law firm has offices in Kentucky, Ohio, and Indiana, states have laws requiring that health care workers report suspected abuse. "The situation will vary from state to state," he says, "but generally, most laws that I have seen require health professionals to report suspected abuse to an adult protective services-type agency."

Indiana’s state law, for example, requires that an agency employee notify his or her superior, who in turn should report to the appropriate state officials — either adult protective services or a law enforcement agency.

Your staff should be aware of the laws, and your agency should have some policy in place and known to staff outlining the course of action for suspected abuse, Gilliland says (see sample policy, p. 91). "You should do inservices so that employees know their responsibilities under state law."

Not complying with the law could lead to criminal or civil action against the staff member or agency for failure to do a duty imposed by law. Professionals could also lose their licenses.

In-Home Health, in Minnetonka, MN, starts the education from orientation, says Cathy Nielsen, RN, CPHQ, vice president of clinical services for the agency. Along with the corporate policies and procedures, they also include various state requirements. California, for instance, has some stricter guidelines than in other states. Those rules have led to some corporate changes, too, says Nielsen. For instance, along with physical, verbal, sexual, and financial abuse, they now also train staff to look for signs of physical, sexual, and financial exploitation. The policies include examples of all of those items, as well as examples of neglect, verbal abuse, and failure to provide care. (See Guidelines for Recognizing Abuse, inserted in this issue.)

Get entire team involved

Nielsen says that when a nurse or aide first suspects something might be amiss, the first step should be to report it to his or her supervisor and call a team conference. "Care conferences can be very helpful to see what other people who have responsibility think might be going on. It also helps in outlining options."

In some cases, what seems like abuse may be something different, she says. For example, what a caregiver sees as a verbal abuse might not seem so to the client. "You have to see how the patient is interpreting it. If the wife is used to being submissive to the husband and it isn’t a problem, maybe you don’t address it."

In cases such as this, it can be helpful to get a social worker involved, Nielsen adds. "They can help you to understand the family dynamics."

If, however, the problem happens in front of your employee and it makes him or her uncomfortable, it should be addressed. "You can make it clear that the person should not behave that way while you are in the house," Nielsen says. "If it continues, then you may want to have a written contract that the behavior will not continue."

In-Home Health’s policy requires the employee to report to the supervisor first. "Usually, they have more experience," Nielsen says. "They can decide if it is something that seems reportable or if further investigation is needed."

The employee is asked to fill out a non-employee unusual occurrence report as well, documenting what he or she observed. The supervisor will talk with other employees involved in the case, get feedback, and perhaps make a home visit herself.

The only exception to that, she says, is if there is an obvious immediate danger to the patient or employee. In that case, the authorities are called immediately. "But if we can, we try to correct the situation in the home environment first."

Consultant Greg George, who owns Healthcare Accreditation Consultants of Fairview, TN, says your policy should include:

A discussion of the chain of reporting suspected abuse.

An outline of the legal responsibilities to report and the penalties for not doing so. Also, include any relevant telephone numbers of state authorities.

Guidelines for recognizing signs of abuse.

George says you should include signs of child abuse, too, if you do pediatric work. If you do, be sure you include a list of characteristics of the non-abusing adult who may also require protective services.

Don’t worry that giving this kind of information to your employees will make them over-report suspected abuse. It isn’t likely, Gilliland says. Even if they do mistakenly report something, in most cases, state law will protect that person and the agency from criminal and civil penalties for making a report in good faith.


Cathy Nielsen, RN, CPHQ, Vice President of Clinical Services, In-Home Health, 601 Carleton Parkway., Minnetonka, MN 55305. Telephone: (612) 449-7500.

John Gilliland II, Gilliland & Associates, Attorneys and Counselors at Law, 211 Grandview Drive, Covington, KY 41017. Telephone: (606) 344-8515.

Greg George, Consultant, Healthcare Accreditation Consultants, 7519 Chester Road, Fairview, TN 37062. Telephone: (615) 799-5867.