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The definition of elder physical abuse is any action by a caregiver that is meant to cause harm or fear in another person Physical abuse includes pain or injury, hitting, pushing, pinching, and grabbing. It is not just physical. It can be intimidation and coercion. About 2 million older adults are victims of elder abuse annually in the United States. Victims of abuse do not always report abuse because they are ashamed, guilty, or afraid of the abuser getting even with them if they report the abuse. Federal and state laws require healthcare professionals to report suspected abuse of the elderly. reporting is called mandatory which is the phrase most often referred to when a profession is required to report. In long-term care facilities employees should always bring suspected abuse cases to the attention of their managers.

Bruising may be the first sign of abuse. It occurs when force is applied to any part of the body that causes blood vessels to break underneath the skin. It is important to be able to tell the difference between bruising that is done on purpose and bruising that is accidental. The locations of bruises can help determine if the bruising is accidental or intentional. Accidental bruising is often seen on one arm or leg. Bruising that should raise suspicions of physical abuse includes bruising on the head, neck, face, buttocks, around the breasts, on the trunk of the body, and/or over the genital area. Bruising on both the upper arms is also suspicious. This type of bruise could mean that the resident was grabbed with the intent to harm. These bruises may turn out to be the result of an accident or possible abuse.

Injuries that have a particular pattern or shape suggest physical abuse. Examples include injuries that have a definite shape like a belt buckle, leave a hand imprint (such as from a slap), produce a round burn indicative of a cigarette burn, or show bruising around ankles or wrists that suggest improper use of restraints. The presence of many injuries that are at different stages of healing may indicate ongoing physical abuse. Another warning sign of physical abuse is when injuries occur but the elderly person cannot explain what happened. Sometimes the reason for the bruise does not seem to make sense. This is another warning sign.

Injuries that are in hidden areas are additional warning signs of abuse. Some abusers make sure to injure parts of the body that are usually covered by clothes. Changes in thinking and behavior can also be warning signs of abuse. Some changes may be part of the aging process or illness. They may also be an elder s response to physical abuse. Depression, confusion, unusual changes in behavior, and sleep changes may be warning signs of abuse. All employees must notice signs of improper use of restraints, drugs, or confinement. Signs of inappropriate restraints include reddened areas, brush burns, or other injuries around residents ankles and wrists that suggest they may have been tied to prevent them from moving. Other examples include locking residents in a room or preventing them from leaving a specific area of the facility. Using drugs to sedate a loud or belligerent resident may make resident sleep for long periods of time, thus preventing him or her from participating in therapy and other activities and interferes with dietary intake. This is an example of inappropriate use of drugs that interferes with the resident s well-being.

A combination of factors including economic, psychological, physical, and social issues can increase the risk for elder abuse. One of the most frequently cited risk factors for abuse is dementia. Research shows that nearly half of nursing home residents have dementia. Depression and other mental health disorders can affect a person s ability to communicate and/or to take care of themselves, placing them at risk for abuse. Inability to effectively communicate, for whatever reason, also increases the risk for physical abuse. Elders who are violent towards others are at risk for becoming involved in physical altercations. There have been cases of long-term care residents assaulting other residents who may fight back physically.

Research shows that the risk for abuse is greater with age. Females over the age of 80 are at greatest risk for abuse. Persons of lower socioeconomic status are also at higher risk. Isolation from family and friends is another risk factor for abuse. In the longterm care setting isolation may take the form of refusing to help residents leave their rooms or making it hard to leave their rooms. Isolation makes it hard for others to note signs of abuse, such as bruising. It also makes it hard for the elder to report their abusers or tell staff that they are afraid. Sometimes cases of older abuse are overlooked. This happens when signs and symptoms are confused with changes related to illness, aging, and declining health. As people get older they often have a need for more physical help with personal care. These extra needs put the resident at a greater risk for abuse.

Males have been found to abuse more often than females. Both men and women abuse elders. Family members are the most common abusers. It is estimated that 90% of elder abuse is committed by a family member. Persons who abuse elders may have feelings of being overly burdened with caring for older adults. Middle managers need to be aware of caregiver stress and fatigue. Often staff are holding a job and/or taking care of children and running a household making the job more stressful. Abusers often lack support systems. Abusers have often been victims of abuse themselves. They may also have a personal history of abuse, lack of support systems, poor coping skills, and problems with substance abuse. Some abusers have a history of being a victim of child abuse or domestic abuse in the past. Victims of abuse often become the abuser. Middle managers should refer staff for employee assistance when a potential for caregiver burn-out or stress is identified. They should also notify senior administration of this concern.

Once abuse is suspected, healthcare professionals must perform a thorough abuse assessment. All concerns about the possibility of abuse should be brought to the attention of managers. The managers must ensure that prompt, thorough abuse assessments are performed. The recognition of injury patterns and the gathering of forensic evidence can help to identify victims of abuse. Injury patterns that are consistent with abuse are: lateral and/or anterior arm bruises, bruising to the head and/or neck, and bruises to the lumbar region.

There are a number of assessment tools you can use to help perform elder abuse assessments. The Elder Assessment Instrument (EAI), is appropriate for all clinical settings. It allows for a review of signs, symptoms, and subjective complaints. Assessment items include, clothing, skin integrity, cuts, broken bones, bruises, nutrition, and incontinence. A head to toe physical assessment is conducted. There is no score for the EAI. The Revised Contact Tactile Scale (CTS2) evaluates locations of bruises and elder explanations about the bruises, such as He punched me. The Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) is the earliest adult abuse screening tool. It has 15 items that cover 3 major areas of elder abuse: violation of personal rights, characteristics of vulnerability, and characteristics of potentially abusive situations. Responses are scored to identify the possibility of abuse. A standardized violence screen asks all elderly residents direct questions to determine actual occurrences of neglect, emotional, physical, sexual abuse, and financial exploitation.

Interventions begin with reviewing the results of a thorough history and physical. In addition to evaluating findings from the history and physical, managers must also take into consideration observations from staff members. Managers should observe staff and their interactions with residents. It is important that middle managers take an active part in surveillance of residents as well. The presence of middle management helps to validate staff concerns and provides the managers with first-hand information about the residents entrusted to their care. Therapeutic communication must be used when interacting with elders. Middle managers serve as role models of communication for their staff. Such communication includes interacting with elders in a supportive, nonjudgmental manner. HIPAA guidelines must be followed at all times. Elders should be given the opportunity to express themselves in privacy, without fear of others overhearing them. The resident s environment within the facility should also be evaluated. The location and condition of their room can indicate a problem with abuse.

The NCEA (2005) Abuse Risk Prevention Profile and Checklist Recommends that careful pre-employment screening be initiated. While it may be tempting to fill vacancies quickly it is important to hire people that are suited to long-term care to reduce the risk of abuse to vulnerable elders. All applicants should be screened for a criminal record and substance abuse. Reference checks should ALWAYS be done prior to hiring an applicant. Middle managers should ask about an applicant s coping skills and attitudes about the elderly. The applicant should be presented with a hypothetical situation during which he/she witnessed another staff member hitting a resident. How would the applicant deal with that type of situation? The applicant could also be asked what he/she would do if fresh bruises over the breasts were found during daily hygiene care. Presenting applicants with real life examples provides some insight as to how an applicant would deal with challenging situations.

All long-term care facilities should have a zero tolerance policy for abuse. Middle managers should model an environment of open communication. This is essential to a culture of safety within any long-term care facility. The facility should have clear-cut staff expectations for all staff to follow. Middle managers should not punish staff members who report suspected abuse. Staff members must communicate directly with their managers to ensure resident safety. Middle managers should demonstrate active listening skills, be approachable and encourage staff to be supportive of each other. The Joint Commission requires that healthcare institutions have criteria in place to identify, assess, and provide appropriate treatment for victims of abuse, neglect or deprivation. In addition to ethical and moral responsibilities healthcare professionals have a legal obligation to report abuse, especially the abuse of children and other vulnerable groups such as elders. There are specific consequences for committing or failing to report the occurrence of abuse. This should be clearly spelled out in policies and procedures relating to elder abuse. Middle managers must alert senior administrators promptly when there is suspected physical abuse in the long-term care setting.

Ongoing education and training on how to recognize and report abuse should be part of the education activities of all healthcare institutions. Training should be frequent, and those who provide the training should be welleducated and provide current, consistent information. Education and training should improve staff competence and knowledge. This can help to reduce stress and burnout among staff members and managers. Education should include recognizing signs of elder abuse and what to do if it is observed or suspected. Education should also address how to deal with physically and verbally combative residents whose behavior can trigger abuse. All staff members should participate in training sessions about working with the elderly population. Middle managers need to track staff participation in educational offerings and facilitate attendance at all mandatory educational offerings. Middle managers should develop a rewards and incentives program for education. A reward system for staff can promote improved job performance.

Reporting of suspected elder abuse must be objective and clearly documented. Incident reports are legal documents and should be completed without bias. Only the facts should be included. Document observations such as, size, shape, exact location of injuries, and date and time injuries were found. Then in quotes add any information the resident is able to provide. Middle managers need to ensure compliance with a facility s quality improvement plan to monitor for any signs of abuse and steps taken to protect residents. Reports and benchmarks for improvement should be shared with senior administration. There are a number of legal implications regarding the reporting of abuse. Mandated reporters are not responsible to prove that abuse has taken place. They only need to state the objective evidence that leads to suspicion of abuse. It is the responsibility of the agency to which the abuse is reported to prove that it occurred. Even if the elder asks the mandated reporter not to report the abuse, healthcare providers are legally required to report it. Failure to report suspected abuse can result in criminal charges and penalties. A report of suspected abuse made in good faith is protected by law from liability.

All residents should be observed for safety at least every hour. A checklist can be used to document routine rounding. Personal care, toileting, and other interactions can be offered during routine rounds. This is also an opportunity for staff to assess the resident s safety and to observe for signs of abuse. Residents should be assessed for bruising or other injuries every shift. Any injuries should be assessed by the nurse in charge and the physician notified as appropriate. Treatment such as cleaning and dressing wounds, applying ice to bruised areas and other interventions should be performed by qualified, professional staff. Senior management should be informed immediately if a resident is suspected to be the victim of elder abuse. Middle managers should communicate with staff about abuse findings in a secure private area. It is important that staff feel comfortable sharing information and that they report immediately so that all details are recorded accurately. Asking residents about any injuries should also be done in private and away from any suspected abuser. All documentation must be evidencebased. Use of a body map to detailing location and type of injuries can be very helpful.

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