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Indirect care providers in a long-term care facility enhance the environment in many ways – such as provision of meals, transportation, security, maintenance, front desk secretary, and environmental services. In carrying out these very important jobs, you interact with residents frequently. Your interactions effect residents in very positive ways. While interacting with residents, it is important to understand professional boundary lines and remember to stay within them. Residents at long-term care facilities appreciate staff members who are kind, respectful, friendly, and who do their jobs well. You are part of the team that takes care of them. Caretakers are friendly and kind but that is not the same as being a friend. Yours is a professional relationship, because the resident is helpless in some ways, and therefore you have power over them. So your relationship is not the same as a friendship. Crossing boundaries and inappropriate conduct often can lead to personal and professional liability or malpractice issues.

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What do we mean by professional boundaries? We must strike a balance between being involved enough and being too involved. Being friendly and helpful is great! But making a resident your friend, like sharing belongings or keeping secrets, is not. It is too confusing for the resident. Often there is a battle of wills between a reluctant resident and a caregiver who is attempting to assist their resident. Establishing a “trusting” relationship over time between care provider and resident is essential for positive results both mentally and physically of the resident.

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You should talk to your supervisor about professional boundaries and what is considered appropriate where you work. Things to avoid include friendships, accepting gifts, and having physical contact such as hugs. Remember, being friendly is not the same as having a friendship. Friendships are not possible because the resident depends on you. So your relationship is not equal. It is essential that the employee remain “respectful” to the resident at all times, especially when working with a resident with a diagnosis of dementia. No matter how awkward the resident’s comments and beliefs are, do not challenge or belittle the resident’s views and always be respectful towards them.

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There are certain things you should never do with residents. In addition to your training, use your common sense to ascertain whether your actions are outside the scope of the resident’s care. These include discussing your personal problems with a resident, having secrets with a resident, spending more time with just one resident, coming to visit a resident during off-duty hours, making financial purchases for the resident, and accepting gifts from a resident. Even if you mean well, you could get in trouble with the laws that protect older people. It is important to avoid the “red flags” and to also avoid the appearance of impropriety.

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Many residents can’t protect themselves because they are disabled or sick. They are more likely to be abused. So are residents who can’t take care of themselves, or can’t think straight or remember things. Some staff in nursing homes are more likely to end up abusing residents. Like those who are overtired from their jobs or stressed out. Staff members who take drugs are also more likely to abuse residents.

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One type of abuse that happens a lot is when caretakers take the resident’s medications. That is a common type of stealing. Other abuse is inflicting injury or pain, yelling at or being mean to a resident, taking a resident’s money, or spending their money for them. Having any kind of sex act with a resident is considered abuse. Neglect is also abuse. That is when a person is supposed to take care of someone else but does not. If a resident appears to be overmedicated, as in over sedated, staff must be made aware as this is considered a form of abuse.

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You might be able to see signs of abuse in the residents you work with. People who are abused might suddenly be unable to care for themselves or have sudden changes in behavior like avoiding people or not talking. Bruising, burns, injuries, or cuts might be from abuse. Confusion, over sedation, hunger, not eating enough, or vomiting could be from abuse or neglect. If a resident has bloody, torn or stained clothing, they may have been abused. Fingerprints or handprints on a resident’s face, neck, arms, or wrist often come from abuse.

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Each state has specific elder abuse laws that must be followed. For example, the state laws in California require administrators, supervisors and licensed staff in long-term care settings to report elder abuse. Some nursing home employees admitted that they suspected abuse but did not report it because they feared revenge, they thought that no one would do anything with the information, or that they were not confident about what they saw. Social workers are often the primary contact with families. It is important to report any information of suspected abuse to facility management staff within 24 hours of the observation.

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Having sex with a resident is a very serious violation. An example is a situation in which a maintenance supervisor was reported for sexual misconduct with residents. He was transporting a resident, who had to run from the car when he made sexual advances. An investigation found that he was fired from his past job for having sex with a resident. This maintenance supervisor’s son visited the nursing home. The next day an 89-year-old resident with Alzheimer’s disease was found with suspicious bruising. She also had fluid and mucus leaking from her vagina. She was taken to a hospital and had a rape exam performed. Reporting to Adult Protective Service is confidential, so there is never a danger that the “reporter” of the abuse will be singled out and face retribution from a co-worker or be exposed. Adult Protective Services keeps a permanent record of employees with judgments against them for maltreatment of older adults.

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You should know how to report a suspected case of elder abuse. You should know where your policies and procedures on elder abuse reporting are located and you should review them regularly. Remember, you don’t have to prove the abuse in order to report it. You just have to have reason to suspect it. If a resident is in life-threatening danger, call 9-1-1 immediately. If you suspect abuse but the resident is not in immediate danger, tell the charge nurse and the supervisor right away. They will make sure that the resident is checked medically and will ask the resident, employee, and witnesses what occurred. Complete the incident report in a timely fashion as soon after the event as possible. Once the resident is checked, the supervisor or administrator will need to contact Adult Protective Services within 24 hours. Other professionals that can be called include the Long-Term Care Ombudsman, and the local police department. Most states have 24-hour hotlines available for elder abuse reporting.

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A Long-Term Care Ombudsman helps to protect residents. The Ombudsman works to resolve resident complaints, and to protect residents from being taken advantage of, abused, or neglected. The Ombudsmen watches out for poor quality of care, rights violations, violations of dignity or self-respect, and theft. Contact information for the Long-Term Care Ombudsman is listed in the “Resource” section at the end of this program.

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Adult Protective Services (APS) responds to all reports they receive. They assign a caseworker who will make sure the resident is safe and understands the process. The caseworker will develop a plan for services for the resident. Services might include medical care, mental health services, emergency shelter, and help with managing finances. The resident has the right to refuse the investigation and/or services offered. Reporting to Adult Protective Service is confidential, so there is never a danger that the “reporter” of the abuse will be singled out and face retribution from a co-worker or be exposed.

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Many times, employees suspect abuse, but do not report it. Reasons they give are that they are unsure exactly what needs to be reported, staffing shortages and feeling overworked, frustrations with their jobs, and the challenge of working with difficult residents.

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Everyone suffers when elder abuse happens. Employees who abuse residents can be arrested by police for fraud or assault charges. Employees can also be personally sued or have protective orders issued against them. The workplace can be charged with abuse or neglect. The long-term facility will also incur future higher expenses, such as insurance premium costs due to elder abuse. Victims of elder abuse can have harm to their bodies and to their emotional health. They may have problems with sleeping and eating, and they may have wounds, injuries, or severe pain. They might suffer from severe anxiety and fear, and be unable to care for themselves. They may even suffer early death.

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Where do sexual assaults occur in nursing homes? Researchers looked at 20 sexual assault cases of residents in nursing homes. All victims had dementia, poor health, or were helpless prior to the attack. Sixteen of the assaults happened in the residents’ beds. One resident was sexually assaulted in her wheelchair. Three victims were taken off of their locked unit and attacked in a different location of the nursing home. In two cases, other staff actually heard the residents yell for help, but did not do anything to try to help the resident. Eleven of these 20 residents died within 12 months after being sexually assaulted due to the trauma and their poor health.

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How can elder abuse be prevented? Prevention is why all newly hired employees have background checks and abuse registry checks. Older adults who reside in long-term care facilities are encouraged to have updated advance directives, living wills, and power of attorney for their finances and healthcare decisions. These things will help reduce the risk of abuse. Ask your supervisor to review workplace policies and procedures related to professional boundaries. Review exactly what type of physical contact is permitted and other relationship guidelines, such as whether gifts are allowed.

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Remember that if you think someone might be abused, you have to report it to your supervisor. Know which residents are at a higher risk for abuse. Review the policies and procedures in your workplace that address professional boundaries, violation of boundaries, and reporting abuse of residents. Be aware of laws in your state that explain who are mandated reporters of elder abuse. Know the symptoms of elder abuse so that you can alert your supervisor if signs of abuse are seen. Reporting a situation to your supervisor when you are suspicious of abuse can help to prevent further abuse and consequences for residents.

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Long-Term Care Ombudsman help older adults in long-term care facilities resolve complaints. The Ombudsman role addresses concerns that involve violation of dignity rights of residents, financial exploitation, poor quality of care, and any other resident concern. When it is found that the resident’s safety is in danger, the local law enforcement agency is contacted. Elder abuse and neglect is a criminal issue and criminal justice systems have been doing a better job addressing these issues. National agencies that address elder abuse include The National Institute of Justice, The Financial Fraud Enforcement Task Force, National Association of Attorneys General, Federal and State Law Enforcement and Corrections-Related Agencies, and the Office for Victims of Crime. Eldercare Locator is a helpful resource provided by the U.S. Administration on Aging. This service assists with finding local resources for older adults such as elder abuse prevention, legal assistance, long-term care, nursing home & long-term care facilities, and financial assistance.

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