Let's look at the list of abuse terms we need to define:
- Aversive Procedures or Deprivation
- Misappropriation of Property
In this course we will use the term "abuse" as a general term to describe the various forms of maltreatment, which is in line with the terminology you will find in our P&P. We will use the term "misconduct" to describe staff behavior that is abusive to residents.
- Physical abuse is staff misconduct that could reasonably be expected to cause physical pain or injury. The act does not have to cause actual injury. Physical abuse also has to be intentional and non-therapeutic, so an accident or event that results from a good-faith effort to provide treatment do not count as abuse.
Examples of physical abuse would be hitting, kicking, punching, slapping, pinching, biting, shoving, or burning.
- Mental abuse is oral, written, or body language that a reasonable person would believe to be distressing, demeaning, disparaging, humiliating, derogatory, harassing, frightening or threatening to another person.
Examples of mental abuse would be shaking a fist in a person's face, yelling, swearing, or throwing an object at or near a person. Sometimes, the abuse is more subtle: staff give residents "cute" nicknames, use sarcasm, tease, or "joke around" with people in a way that degrades them or makes them uneasy.
Can you think of other examples?
Take a look at the "11 Kinds of Disrespect."
These are some of the more subtle ways that residents might be mistreated.
11 Kinds of Disrespect
- Intentionally avoiding or ignoring one individual while giving attention to another.
- Any form of retaliation by staff.
- Destroying trust by making unreasonable promises.
- Ignoring complaints.
- Speaking about a resident in front of her as though she is not there.
- Not respecting the person's status as an adult.
- Not respecting physical and emotional privacy.
- Denying an individual's feelings and choices.
- Demonstrating low expectations of a resident.
- Setting an individual up to fail.
- Withholding pertinent information from a resident.
- Sexual abuse. In this context we are talking about staff actions with consumers. Period. It does not matter who initiates the contact; it is still considered sexual abuse by the staff person. There are three types of sexual abuse:
- Sexual conduct or molestation. This is intentional touching or fondling of the breast, genitals, or anus.
Example: A staff person fondles the breasts of a resident while she sleeps.
- Sexual penetration. This is any contact between the sex organ of one person and the sex organ, mouth or anus of another person; or anything else inserted into the sex organ or anus of another person.
Example: A staff person engages in oral sex with a resident.
- Sexual exploitation. This is the sexual use of another person for gratification, advantage or profit.
Example: A staff person takes a nude photo of a resident and sells it to another person.
- Aversive procedures or deprivation we classify together because they both are basically punishment. You are not allowed to hand out your own consequences for behaviors you don't like. Here are some examples of aversive or deprivation procedures. Unless they are spelled out in the person's ISSP/behavior plan/doctor's order–and most wouldn't be–these are bad ideas:
- Taking away a person's dinner;
- Taking away any of a person's stuff;
- Limiting a person's water intake;
- Restricting a person's normal access to adequate ventilation, hygiene facilities, medical attention, legal counsel, and necessary clothing;
- Denying a person her normal contact with family or friends.
Abuses are the result of staff acts.
Neglect, on the other hand, is more often due to omissions
: intentional failures to act.
Neglect happens when a resident, due to staff negligence, does not get what she needs, such as:
- Regard for his/her rights
- The amount of supervision s/he needs to be safe and healthy
- The amount of attention s/he needs for mental and emotional health
When it comes to attention, at least two things need to be said to address common staff mistakes: 1) In general, when a resident seeks your attention, give it.
The person may seek attention in an inappropriate way but there's still a basic human need behind the behavior. And, 2) If a behavior plan calls for "planned ignoring" of a particular behavior make sure that it is only the target behavior you ignore, not the person
Some examples of neglect:
- A resident burns her hands repeatedly on the kitchen stove. No one bothers to take steps to prevent this from happening again and again.
- A resident soils himself and is unable to clean himself up. Staff are aware that he is soiled but finish paperwork before someone helps out 45 minutes later.
- A door alarm sounds. The staff person decides not to check on it because it malfunctions sometimes. When she finally does check a few minutes later, a resident is missing.
- Three residents of a CBRF require staff on the premises at all times, but the overnight staff leaves the house at midnight for 10 minutes to go buy a soda.
Can you think of other examples, or do you have a question about whether something would be neglect?
As these examples show, harm doesn't necessarily have to happen for the problem to be neglect. Only the risk
of some sort of physical, mental, or emotional damage arising from staff carelessness or negligence has to occur, no matter the actual outcome.
- Restraint can be physical or chemical.
- Physical restraint is any manual technique or device that interferes with a person's freedom of movement, normal functioning, or normal access to a part of the person's body–and is difficult for the person to remove him/herself. Putting someone in a locked room would also be physical restraint.
- Chemical restraint is when psychotropic medication is used for convenience or discipline and not required for treating medical symptoms.
Are restraints ever
OK? Yes. In an emergency you may use restraint; for example, to keep a person from running into the street in front of a car. Also, physical restraint may be approved for use under these circumstances:
- DHFS must approve use of the restraint and may place conditions on its use; for example, set how often a person in restraint must be checked on
- The resident's primary doctor must authorize use of a restraint in writing
- Only staff trained in the proper use of a restraint may apply it
Follow all procedures and conditions to the letter.
- Any use of a restraint, including adverse reactions to it, must be documented in the resident's record
Restraints can be dangerous. For example, people can have trouble breathing while restrained in certain positions or for too long. Never feed a person who is in restraints. Also, think about if someone couldn't move or leave a room and you suddenly had to evacuate the house because of fire.
Use of medication as part of a behavior management plan is OK as long as these conditions are met:
- The person must be free of unnecessary or excessive medication
- Medication must never be used as punishment
- Medication cannot be used for staff convenience
- Medication cannot be used as a substitute for a proper, comprehensive treatment plan
Medication used properly and meeting these conditions is not considered chemical restraint.
- Seclusion means that staff have taken action to separate a resident physically or socially from others.
We are normally not allowed to make this kind of separation. The only times we should are:
- When we are properly following a behavior treatment plan.
- When a person has a contagious disease and we are following quarantine protocol.
- Or, when a resident has voluntarily agreed to a cooling-down period in an unlocked room. We cannot just "send" people to their rooms whenever we feel like it.
- Misappropriation of Property can happen with a person's money or other property.
- using or taking away a resident's property without permission, with intent to deprive her of it
- gaining the person's property by deceiving them (e.g., making a promise with no intent to keep the promise)
- using a resident's money in any way that is not specifically authorized
Indicators of Abuse
What our policy requires is that you report all indicators. Your report will trigger decisions on the actions needed to correct the situation.
- using a resident's i.d.(s) to obtain something of value
There are four kinds of indicators of abuse: physical, verbal/vocal, behavioral, and circumstantial. The first three are what you observe of residents. Circumstantial indicators are what you observe about other staff. Some of these indicators are contained in Appendix IV of Dungarvin P&P B-2 so you have access to a list anytime. Even so, now is a good time to ask any questions you have so far about these indicators.
- Physical Indicators are visible marks found on a person's body or clothing; pain; evidence of deception or fraud; or missing property.
Since there are so many of these physical indicators, we will further break down this category 4 ways into physical indicators of physical abuse, sexual abuse, neglect, and material abuse.
- Of physical abuse examples are cuts, scrapes, puncture wounds, swellings, bone fractures, sprains, dislocations, broken teeth, missing patches of hair, welts, or burns; evidence of over-medication; pain with no physical marks visible; bruises, especially those with unusual shapes or on parts of the body that usually don't get injured (for instance, the back).
Some people get bruises and such regularly just in the course of their usual activity. Watch that the explanation for an injury fits the type of injury involved.
- Of sexual abuse physical indicators would include genital or anal abnormalities such as pain, bleeding, bruising, discharge, swelling and/or itching. There might be frequent and/or painful urination, sexually transmitted disease (STD) or pregnancy.
Also, blood or semen on clothing, towels, or bedding, or torn or missing clothing are indicators.
- Of neglect the physical indicators would be that the person has an odor, is not dressed for the weather, has soiled clothing or bedding, has untreated medical and/or dental problems, has dehydration without illness that would explain it; has constant hunger or weight loss.
You might see physical indicators in the house itself: lack of food in the home, unsafe or unsanitary conditions, repairs needed.
- Of material abuse you see signatures on checks that don't look like the person's signature; personal belongings might be missing, or evidence of financial deception.
- Verbal/Vocal Indicators have to do with what the resident is saying, or in the case of someone who cannot speak, what vocalizations or other noises the person is making.
Examples: Unusual or prolonged crying or screaming; unusual or prolonged crying or screaming in the presence of a particular person; complaints of not being treated well by a particular person; or accusation that a person has abused him/her.
Also: contradictory statements; unexplained or unusual new knowledge or words of a sexual nature; expressed interest in a new sex-related topic that cannot be explained; new complaints of pain in neck, back or genitals; complaints of frequent headaches or other aches, pains or illness.
- Behavioral Indicators of abuse or neglect are actions that another person can observe; especially sudden behavior changes.
- Abuse indicators: Increased aggression; dramatic mood changes; sudden withdrawal from activities the person used to enjoy; changes in eating habits; changes in sleeping patterns; anxiety; ambivalence; suicidal gestures; reappearance of old behavioral challenges; fear of certain people, places or objects; fear of confinement; overcompliance; non-responsiveness; or running away.
- Neglect indicators: person begs or steals food.
Watch for sudden avoidance patterns
: a resident who always goes to bed at 10 p.m. has begun staying up very late and resists suggestions to go to bed earlier. A resident starts avoiding a certain person or a certain area of the house, or doesn't want to take baths anymore, etc.
- Circumstantial Indicators are what we can observe about other caregivers.
Examples: negative behavior such as hostility, anger, disrespect, apathy, or callousness toward self and others; history of maltreating others; threatening to harm others; joking about harming others; finding humor in the pain and suffering of others; alcohol or drug abuse.
Circumstantial indicators specifically for sexual abuse would include all the examples we've covered so far, plus a couple more:
- Caregiver seeks isolated contact with particular individuals
- Caregiver seems preoccupied with sex: brings pornographic material to work, or engages in sexual harassment or other inappropriate or excessive eroticism
- All program staff are mandated reporters when it comes to abuse. If you suspect abuse of a resident, you must immediately contact your supervisor to report it. This is a legal obligation and penalties can be imposed if you do not meet this obligation. If your supervisor is the accused, or not available, contact the on-call supervisor, Area Director or Senior Director.
- You are authorized to contact law enforcement if you believe protection is needed to prevent further victimization.
- You have a right to be protected from reprisal from the accused person.
- A report triggers a number of actions:
- An Investigator is assigned
- If necessary, steps are taken to protect the alleged victim from reprisal
- Medical attention is sought if needed for the victim for treatment of injury &/or sexual assault exam
- Family and/or guardian is notified
- DHFS is notified within 24 hours (if a weekend or holiday, the first working day after).
- The Investigator completes a written summary of the report and investigation findings.
- An employee found to have abused or neglected a resident will be reprimanded, given a probationary warning, or dismissed.
- Reporting helps prevent abuse. Abuse and neglect will happen sometimes in a population that is as vulnerable as the one we work with. If you report it when you witness it, you have a hand in prevention in several ways:
- You help prevent further victimization of the resident
- You help prevent other residents from being victimized
What about false reports?
- You help cultivate an atmosphere that does not tolerate maltreatment, which by the way is good not only for the residents but for your own working conditions, if you think about it.
Do they happen? Yes. Should you worry about it? Probably not. Investigators are allowed to take into account a resident's past history in making false reports.
Please do not make your own "judgment call" with a person who has a reputation for false reports. Like the boy who cried wolf, residents who make false reports may be in the most danger of all. Report indicators regardless of where they come from.