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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America 14 Elder Abuse in Residential Long-Term Care Settings: What Is Known and What Information Is Needed? Catherine Hawes* There has been very limited research on elder abuse, although there is some evidence that suggests it may be nearly as widespread in the community as child abuse (Bourland, 1990; Fulmer, 1989; Kleinschmidt et al., 1997; National Center on Elder Abuse, 1998; Pillemer and Finkelhor, 1988; U.S. House of Representatives, 1990). Although attention has increased somewhat in recent years, most research on elder abuse and neglect has focused on incidence, causes, and risk factors in the community. Elderly who live in settings other than their own homes or apartments or those of relatives have received relatively little attention from either the research or policy communities. However, elderly who live in residential settings that offer long-term supportive services are at particular risk for abuse and neglect.1 They are particularly vulnerable because most suffer from several chronic diseases that lead to limitations in physical and cognitive functioning and are dependent on others (Spector et al., 2001). In addition, many are either unable to report abuse or neglect or fearful that * Catherine Hawes, Ph.D., is a professor in the Department of Health Policy and Management, School of Rural Public Health, at Texas A&M University System Health Science Center. 1 Marshall and his colleagues assert that elder abuse is more common in homes than in institutional or residential facility settings but offer no evidence to support this assertion (Marshall et al., 2000). What they ignore is that although there may be more cases of community-dwelling elderly, proportionally, there may be more cases in residential/institutional long-term care settings.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America such reporting may lead to retaliation or otherwise negatively affect their lives (Hayley et al., 1996). Thus, as Shapira (2000) noted, “The elderly in skilled nursing facilities are among the most vulnerable members of our society. They are dependent on the . . . nursing facility operator for their food, medicine, medical care, dental care, and a bed; a roof over their heads; for assistance with virtually every daily activity.” On any given day, approximately 1.6 million people live in approximately 17,000 licensed nursing homes, and another estimated 900,000 to 1 million live in an estimated 45,000 residential care facilities, variously known as personal care homes, adult congregate living facilities, domiciliary care homes, adult care homes, homes for the aged, and assisted living facilities (Strahan, 1997; Hawes, et al., 1999, 1995a). Research suggests that the 2.5 million vulnerable individuals in these settings are at much higher risk for abuse and neglect than older persons who live at home, as discussed below. Moreover, these figures may underestimate the number of persons who are actually at risk for abuse or neglect in a nursing home. Based on data from the National Mortality Followback Survey, researchers estimate that more than two-fifths (43 percent) of all persons who turned 65 in 1990 or later will enter a nursing home at some time before they die (Kemper and Murtaugh, 1991; Murtaugh et al., 1990). Moreover, of those who enter a nursing home, more than half (55 percent) will have a total lifetime use of at least one year. The probability of use increases dramatically with age, rising from 17 percent for those aged 65 to 74 to 60 percent for persons aged 85 to 94. Because women live longer than men, their relative risk of lifetime use of a nursing home is higher (i.e., 52 percent versus 33 percent). In addition, because the most rapidly growing segment of the population is those aged 85 and older, the proportion of persons estimated at risk for nursing home use at some time in their lives is expected to increase over time. Thus, while only 2.5 million elders living in a residential long-term care facility on any given day may be at risk for abuse, over their lives many elderly may be at risk during a period of long-term care facility use. The general goals of this paper are to present the available evidence about the nature and scope of abuse and neglect in nursing homes and other residential care facilities and the causes, as well as to suggest a research agenda. To accomplish these goals, the paper is organized as follows: Section 2 presents definitions of abuse and neglect; Section 3 provides the available evidence about the nature and scope of abuse and neglect in nursing homes; Section 4 presents the available evidence about the nature and scope of abuse and neglect in residential care facilities; Section 5 explains the limitations of these estimates;
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Section 6 discusses the sample design and data collection issues associated with studies to determine the prevalence of abuse and neglect in nursing homes and residential care facilities; Section 7 discusses what is known about the causes of abuse and neglect and presents the author’s recommendations for additional research. DEFINITIONS OF ABUSE AND NEGLECT The definition of physical abuse is the area about which there is the greatest agreement, both in terms of being “wrong” and in terms of what constitutes physical abuse; it involves injury or harm to a person carried out with the intention of causing suffering, pain, or impairment (Clarke and Pierson, 1999; Lachs et al., 1994; Lachs and Pillemer, 1995; Tatara and Kuzmeskus, 1996–1997). The Administration on Aging, in its instructions to long-term care ombudsmen, defines abuse as “the willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm, pain, or mental anguish or deprivation by a person, including a caregiver, of goods or services that are necessary to avoid physical harm, mental anguish, or mental illness” (1998:13). This is consistent with the definition used by the Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration) in its guidelines to the states on reporting of abuse and neglect in nursing homes, as reported below. Physical abuse is generally thought to include hitting, slapping, pushing, or striking with objects. In nursing homes, other types of actions have been included, such as improper use of physical or chemical restraints. Physical abuse also typically includes sexual abuse or nonconsensual sexual involvement of any kind, from rape to unwanted touching or indecent exposure.2 There is somewhat less agreement about whether verbal or psychosocial abuse should be included in the general category of abuse when applied to older persons. This is generally thought of as “intentional infliction of anguish, pain, or distress through verbal or nonverbal acts” and includes threats, harassment, and attempts to humiliate or intimidate the older person (Clarke and Pierson, 1999:632). In focus group interviews conducted in 2000 (Hawes et al., 2001), 2 Clarke and Pierson (1999:635) argue that examples (or possibly indicators of potential abuse and neglect) of abuse are “falls and fracture, physical or chemical restraints, malnutrition, dehydration, bed sores, defective equipment, lack of supervision, weight gain or loss, theft of money and personal property, unexpected or wrongful death, unsanitary conditions, untrained or insufficient staff, over-sedation, substandard medical care, and poor personal hygiene.”
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America certified nursing assistants (CNAs) defined abusive actions that included both physical and verbal or psychological abuse, such as: aggressiveness with a resident; rough handling; pulling too hard on a resident; yelling in anger; threats; punching, slapping, kicking, hitting; and speaking in a harsh tone, cursing at a resident, or saying harsh or mean things to a resident. Neglect of older persons is another area that has received increased attention in recent years. As Clarke and Pierson noted, “Definitions of neglect are probably the most disputed of any category” of maltreatment of elderly persons (Clarke and Pierson, 1999:632). However, in general, neglect is thought of as including “the refusal or failure of a caregiver to fulfill his or her obligations or duties to an older person, including . . . providing any food, clothing, medicine, shelter, supervision, and medical care and services that a prudent person would deem essential for the well-being of another” (Clarke and Pierson, 1999). CNAs who participated in focus groups also had very clear and specific ideas about what constituted neglect in nursing homes (Hawes et al., 2001). They mentioned a number of examples: no oral/dental care; not doing range of motion exercises; not changing residents each time they are wet after an episode of incontinence; ignoring residents who are bedfast, particularly not offering activities to them; not doing prescribed wound care; not giving residents regular baths; doing a one-person transfer when the resident requires a two-person transfer; not providing cuing or task segmentation to residents who need that kind of assistance to maximize their independence; not doing scheduled toileting or helping residents when they ask; not keeping residents hydrated; and turning off a call light and taking no action on the resident’s request. The federal government also has formal definitions of abuse and ne-
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America glect in nursing homes. The nursing home reforms contained in the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987. Pub L. No. 100-203) specified that nursing home residents had the “right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion” (42 CFR Ch. IV (10-1-98 Edition) §483.13 (b)). HCFA issued regulations and guidelines implementing these provisions of the OBRA 1987 legislation. These regulations specified the following definitions: Abuse means the willful infliction of injury, unreasonable confinements, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The federal regulations implementing OBRA 1987 also specified long-term care facilities’ responsibility to “develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property” (42 CFR Ch. IV (10-1-98 Edition) §483.13 (c)). Furthermore, the law required that the facility “must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law or have had a finding entered into the state nurse aide registry concerning abuse, neglect, mistreatment of residents, or misappropriation of their property” (42 CFR Ch. IV (10-1-98 Edition) §483.13 (c)(1) (ii) (A) (B)).3 EVIDENCE ABOUT THE NATURE AND PREVALENCE OF ABUSE AND NEGLECT IN NURSING HOMES For decades, nursing homes have been plagued with reports suggesting widespread and serious maltreatment of residents, including abuse, neglect, and theft of personal property (Douglass et al., 1980; Fontana, 1978; Institute of Medicine, 1986; Mendelson, 1974; Moss and Halamandaris, 1977; New York State Moreland Act Commission, 1975, 1976; Ohio General Assembly Nursing Home Commission, 1978; Stannard, 1973; U.S. Senate, 1970; U.S. Senate, 1971; U.S. Senate Special Committee on Aging, 1974– 1975; Vladeck, 1980). In addition, a number of case studies, participant-observation studies, interviews with nursing home staff, and interviews with residents and ombudsmen provided evidence of abuse (Doty and 3 This lifetime ban was modified in certain cases under provisions of the 1997 Balanced Budged Act. Balanced Budget Act of 1997, Conference Report to Accompany H.R. 2015. 105th Congress, 1st Session. House of Representatives, Report 105-217 (July 30, 1997).
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Sullivan, 1983; Douglass et al., 1980; Fontana, 1978; Gubrium, 1975; Jacobs, 1969; Kayser-Jones, 1990; Monk et al., 1984; Stannard, 1973; U.S. House of Representatives, Select Committee on Aging, 1990). Such conditions were major factors in the passage of the nursing home reforms contained in the Omnibus Budget Reconciliation Act (OBRA) of 1987 (OBRA, 1987).4 The OBRA 1987 reforms, the most sweeping set of legislative changes to the way nursing homes were regulated since the passage of Medicaid and Medicare, addressed multiple areas of resident care and quality of life. They also specified that residents had the right to be free from verbal, sexual, physical, and mental abuse, including corporal punishment and involuntary seclusion, and limited the use of physical restraints and inappropriate use of psychotropic medications (Hawes, 1990; Elon and Pawlson, 1992). Despite this federal law and reports over the preceding decades that raised the possibility of widespread and serious abuse, there has never been a systematic study of the prevalence of abuse in nursing homes. Indeed, it is important to note that none of the studies discussed below involving interviews with residents or with facility staff were designed with the intention of producing generalizable estimates to the nation as a whole. Nevertheless, the disparate evidence that is available and discussed below suggests the existence of a serious problem that warrants further study. Resident Risk Factors Several studies have examined the characteristics of individuals living in community settings (e.g., their own home or that of others) in an attempt to identify factors that place an older person at greater risk for being abused or neglected. Such studies found that persons suffering abuse or neglect were more likely to be old and nonwhite and to have greater limitations in physical and cognitive functioning, although there has been some disagreement about whether functional impairment in the activities of daily living (ADL) is a risk factor for abuse (Bristowe and Collins, 1989; Johnson, 1991; Lachs et al., 1994; Lachs et al., 1996, 1997; Pillemer and Finkelhor, 1988; Podnieks, 1992). However, there is strong evidence that the presence of cognitive impairment or dementia is associated with higher risk for being abused (Coyne et al., 1993; Dyer et al., 2000; Homer and Gilleard, 1990; O’Malley et al., 1983; Paveza et al., 1992; Pillemer and Finkelhor, 1988; Pillemer and Suitor, 1992; Wolf and Pillemer, 1989). Studies of individual risk factors for elderly living in residential long-term care facilities are more limited but generally suggest the existence of 4 The Omnibus Budget Reconciliation Act of 1987 ~ PL 100-203.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America TABLE 14-1 Characteristics of Nursing Home Residents Characteristic Percent Aged = 85 years 49 Nonwhite 9 Receives assistance with =3 ADLs 83 Mild to moderate cognitive impairment 71 Exhibits physically aggressive behaviors 9 Exhibits any behaviors (e.g., verbally or physically aggressive, resists nursing care, socially inappropriate) 30 SOURCE: Krauss and Altman (1998). similar risk factors for individual residents. For example, Burgess and her colleagues argued, “The risk for abuse increases simply as a function of their dependence on staff for safety, protection, and care” (Burgess et al., 2000). They found that a diagnosis of Alzheimer’s or other dementia or some type of memory loss or confusion was present at a somewhat higher rate among nursing home residents who had been sexually abused than among the average nursing home population, although those data were from a small case study (Burgess et al., 2000). Similarly, the findings from another study suggest that residents with behavioral symptoms, such as physical aggressiveness, appear to be at higher risk for abuse by staff (Pillemer and Bachman-Prehn, 1991), a finding supported by focus group interviews with CNAs (Hawes et al., 2001) and studies of precipitating factors among community-dwelling elders who have been abused (Pillemer and Suitor, 1992; Ehrlich, 1993). Unfortunately, dependence on others for help with physical functioning and impairment in cognitive functioning are common among the vast majority of nursing home residents, and difficult or challenging behaviors are not uncommon, as displayed in Table 14-1. These behaviors are often a product of neurological changes, memory loss, and communication deficits associated with diseases such as Alzheimer’s. However, many staff members often view aggressive resident behaviors or attempts to resist care as intentional attempts by the resident to be difficult or to hurt staff, a belief
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America that makes such residents more likely to be handled roughly or abused by staff (Hawes et al., 2001). Reports of Abuse from Residents and Families I saw a nurse hit and yell at the lady across the hall because the nurse told the lady she didn’t have all day to wait on her. The lady made some remark. The nurse hit the lady and said, “Shut up.” Georgia Nursing Home Resident (Atlanta Long-Term Care Ombudsman Program, 2000) A few studies have interviewed residents and family members about their experiences in nursing homes and asked specific questions about abuse. The Atlanta Long Term Care (LTC) Ombudsman Program (Atlanta Long-Term Care Ombudsman Program, 2000) conducted the most recent study under a grant funded by the National Ombudsman Resource Center. In this study, ombudsmen interviewed 80 residents in 23 nursing homes in Georgia.5 This survey found that 44 percent of the residents reported that they had been abused, while 48 percent reported that they had been treated roughly. For example, one resident noted: They throw me like a sack of feed . . . [and] that leaves marks on my breast. Georgia Nursing Home Resident (Atlanta Long-Term Care Ombudsman Program, 2000) In addition, 38 percent of the residents reported that they had seen other residents being abused, and 44 percent said they had seen other residents being treated roughly. For example, as one resident reported: My roommate—they throw him in the bed. They handle him any kind of way. He can’t take up for himself. Georgia Nursing Home Resident (Atlanta Long-Term Care Ombudsman Program, 2000) 5 The ombudsmen initially identified what they considered 10 problem facilities and recruited residents from those nursing homes. The process was subsequently expanded to a total of 23 facilities, based on local ombudsman identification of residents willing to speak with the interviewers about issues of abuse and neglect. The authors reported, “Almost all those approached agreed to be interviewed.” Those who declined cited fear of retaliation. Finally, the ombudsmen used CMS Survey protocols to identify “interviewable” residents in long-term care facilities (Atlanta Long-Term Care Ombudsman Program, 2000).
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Focus groups and individual interviews with residents and family members for a study of the nursing home complaint-investigation process also produced reports of abuse and severe neglect. Families reported finding residents with bruises and abrasions, unexplained falls, some of which caused fractures, and residents left for days with broken bones before the family or resident’s physician were notified, such as the case reported below. Have I seen abuse? No, not directly. But I’ve come in and found my mom battered and bruised. I mean, her whole face was bruised and swollen, the backs of her hands and arms were bruised, as if she tried to protect herself. Daughter of a Texas Resident, 1999 (Hawes et al., 2000) Reports of Abuse from Facility Staff Oh, yeah. I’ve seen abuse. Things like rough handling, pinching, pulling too hard on a resident to make them do what you want. Slapping, that too. People get so tired, working mandatory overtime, short-staffed. It’s not an excuse, but it makes it so hard for them to respond right. CNA from South Carolina (Hawes et al., 2000) A 1987 survey of 577 nursing home staff members from 31 facilities found that more than one-third (36 percent) had witnessed at least one incident of physical abuse during the preceding 12 months (Pillemer and Moore, 1989).6 As displayed in Table 14-2, such incidents included excessive use of physical restraints (21 percent); pushing, shoving, grabbing, or pinching a resident (17 percent); slapping or hitting (13 percent); throwing something at a resident (3 percent); kicking or hitting with a fist or object (2 percent). Ten percent of the staff members surveyed reported they had committed such acts themselves. A total of 81 percent of the staff reported that they had observed and 40 percent had committed at least one incident of psychological abuse during the same 12-month period. Psychological abuse included yelling in anger, insulting or swearing at a resident, inappropriate isolation, threatening to hit or throw an object, or denying food or privileges. Yelling at a resident in anger and insulting or swearing at a resident were the most common acts observed, with 70 percent having observed yelling and 50 percent having observed a staff member insulting or swearing at a resident 6 Thirty-one of a potential sample of 77 facilities in one state met the facility size criteria, agreed to participate in the study, and provided complete lists of staff.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America TABLE 14-2 Results of Surveys of CNAs about Committing or Witnessing Abuse and Neglect of Residents Rates of Self-Reported Behaviorsa Abusive Behaviors Pillemer and Moore (percentage) Pillemer and Hudson (percentage) Yelled at a resident in anger 23 51 Insulted or swore at a resident 10 23 Threatened to hit or throw something at a resident 2 8 Pushed, grabbed, or shoved 3 17 Slapped or hit a resident 3 2 Thrown something at a resident 1 1 Excessive use of physical restraints 4 Not reported Rates of Behaviors Witnessed by CNAs Not Asked Yelling at a resident 70 Insulting or swearing at a resident 50 Excessive use of physical restraints 21 Pushing, grabbing, shoving, or pinching 17 Slapping or hitting a resident 13 Throwing something at a resident 3 Kicking or hitting a resident 2 aPillemer and Moore (1989) surveyed 577 staff (nurses and CNAs) about incidents over a 12-month period. Pillemer and Hudson (1993) interviewed 211 staff about incidents during the preceding 1-month period. (Pillemer and Moore, 1989). Interviews with more than 200 staff members who subsequently participated in an abuse-prevention training program also indicated substantial levels of abusive behaviors by staff caregivers in nursing homes. Focus groups with CNAs also provided quantitative and qualitative data that supported the findings reported by Pillemer and Moore. For example, North Shore Elder Services in Danvers, Massachusetts, conducted a recent project on reducing abuse and neglect in nursing homes (MacDonald, 2000). In this project, 77 CNAs from 31 nursing facilities received training. As part of this project, CNAs were surveyed about whether they had witnessed any incidents of abuse or neglect. Verbal abuse was reported as fairly common: 58 percent of the CNAs said they had seen a staff member yell at a resident in anger; 36 percent had seen staff insult or swear at a resident; 11 percent had witnessed staff threatening to hit or throw something at a resident (MacDonald, 2000).
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America These CNAs also reported that they had witnessed incidents of rough treatment and physical abuse of residents by other staff. Twenty-five percent of the CNAs witnessed staff isolating a resident beyond what was needed to manage his/her behavior; 21 percent witnessed restraint of a resident beyond what was needed; 11 percent saw a resident being denied food as punishment. In addition, the staff reported witnessing more explicit instances of abuse. Twenty-one percent saw a resident pushed, grabbed, shoved, or pinched in anger; 12 percent witnessed staff slapping a resident; 7 percent saw a resident being kicked or hit with a fist; 3 percent saw staff throw something at a resident; and 1 percent saw a resident being hit with an object. Reports of Abuse from Health Care Professionals There are relatively few studies of health care professionals and issues of abuse of nursing home residents, and most that exist focus on underreporting and reasons for that phenomenon. However, one study did suggest that abuse might be widespread. Emergency department physicians conducted retrospective chart review of 328 nursing home residents admitted to the emergency room. In nearly 1 in 5 (19 percent) of 253 cases with adequate documentation of when the injury occurred, there was an unexplained delay in seeking medical treatment of 24 hours or more (Barlow et al., 1998). Reports of Abuse from Ombudsmen and Adult Protective Services Agencies Another source of information on abuse and neglect in nursing homes is data from the Long-Term Care Ombudsman program. The ombudsman program was established in the early 1970s to “identify, investigate, and resolve individual and systems level complaints” that affect residents in nursing homes and residential care facilities (Huber et al., 2001:1). Federal funds for the program are through the Older Americans Act, and some programs also receive state funding (Huber et al., 1996). For some years, ombudsmen have reported incidents of abuse and neglect in nursing homes (Monk et al., 1984). For example, one study that surveyed agencies in 22 states reported 15,612 cases involving allegations of abuse of nursing home residents received by such agencies as Adult Protective Services, ombudsmen, and state Medicaid fraud units, which are responsible for prosecuting abuse cases involving nursing homes (Tatara, 1990). Reports of abuse and neglect from ombudsmen are thought to have
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America and types of abuse and neglect. In particular, one might follow up on Vince Mor’s “good nursing home study” (Mor et al., 1986) and Bowers and Becker’s work (1992) to determine whether certain management styles are associated with less abuse and neglect. Examine the effect of environmental factors (e.g., that make work in nursing homes more or less difficult or burdensome for staff) and more or less confusing (or in the case of bathrooms, unfamiliar and disturbing) for residents with cognitive impairment. Identify and evaluate any model employee screening and hiring practices. Evaluate the effects of different staffing models, particularly use of permanent staff assignment to a group of residents (e.g., the primary care model versus the floating CNA model). Evaluate the effect of different staffing patterns, particularly in terms of staff-to-resident ratios, on the prevalence and severity of abuse and neglect. Identify and evaluate interventions aimed at CNAs that are intended to improve quality or explicitly to prevent abuse. The one most highly regarded by ombudsmen is a training program developed by an advocacy group, the Coalition of Advocates for the Rights of the Infirm Elderly (CARIE), and researcher Karl Pillemer. This program has been evaluated and found to be effective in changing both staff attitudes and behaviors (Pillemer and Hudson, 1993). It would be useful to examine the extent to which the effects persist and whether effects vary across different facility types (e.g., different management styles, different staffing patterns and staffing levels). Another training program worth evaluation might be the one developed by North Shore Legal Services Program (MacDonald, 2000); however, they found difficulties in maintaining and expanding the intervention in facilities. Evaluate staff empowerment models, such as Wellspring. Such research should include an analysis of the conditions under which such interventions will be adopted, fully implemented, and maintained over time in various types of facilities. Evaluate models of culture change, such as the Eden Alternative, to determine whether they reduce the prevalence or severity of abuse and neglect. Such research should include an analysis of the conditions under which such interventions will be adopted, fully implemented, and maintained over time in various types of facilities. Evaluate the effect of different regulatory systems. For example, Washington state has been identified as having a model program for quality assurance and for detection and prevention of abuse and neglect, and ombudsmen, facility administrators, and state agency nurse aide registry staff
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America report that incidents of physical abuse are much less common than the rates reported in other states (Hawes et al., 2001; Hawes, based on site visit interviews in 2001). REFERENCES Administration on Aging 1998 Instructions for Completing the State Long-term Care Ombudsman Program Reporting Form for the National Ombudsman Reporting System (NORS). Washington, DC: Department of Health and Human Services, Office of the Secretary of the Administration on Aging. 2000 FY 1998 Long-Term Care Ombudsman Report with Comparisons of National Data for FY 1996-1998. Washington, DC: Administration on Aging, Department of Health and Human Services. Available at: http://www.aoa.gov/ltcombudsman/98report/98finalreport.html. American Medical Association 1992 Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. Chicago, IL: American Medical Association. American Seniors Housing Association 1998 Seniors Housing Construction Report—1998. Washington, DC: American Seniors Housing Association. Assisted Living Federation of America (ALFA) 1998 The Assisted Living Industry: An Overview—1998. Fairfax, VA: Price Waterhouse for ALFA. Atlanta Long-Term Care Ombudsman Program 2000 The Silenced Voice Speaks Out: A Study of Abuse and Neglect of Nursing Home Residents. Atlanta, GA: Atlanta Legal Aid Society and Washington, DC: National Citizens Coalition for Nursing Home Reform. Avorn, J., P. Dreyer, K. Connely, and S.B. Soumerai 1989 Use of psychoactive medication and the quality of care in rest homes. New England Journal of Medicine 320(4):227–232. Baldwin, V.R. 1992 An Analysis of Subjective and Objective Indicators of Quality of Care in North Carolina Homes for the Aged. Dissertation, University of North Carolina at Chapel Hill, School of Public Health, Department of Health Policy and Administration. Barlow, B., C. Puetz, J.S. Jones, and D.J. Ray 1998 Institutional ‘accidents’: Is emergency department documentation adequate for assessment of elder abuse? Annals of Emergency Medicine 32(3)(Supplement, Part 2) :S60. Baron, S., and A. Wellty 1996 Elder abuse. Journal of Gerontological Social Work 25(1/2):33–57. Bates, E. 1997 Mining the golden years: Homes for the elderly dig deep into tar heel politics— and hit pay dirt. The Independent. A series that ran from April 30 to May 6, 1997. Bernabei, R., G. Giovanni, K. Lapane, F. Landi, C. Gatsonis, R. Dunlop, L. Lipsitz, K. Steel, and V. Mor 1998 Management of pain in elderly patients with cancer. Journal of the American Medical Association 279(23):1877–1882.
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