Gerontologic nursing Chapter 3: Legal and Ethical Issues Professional Standards Health care providers have a general obligation to live up to accepted or customary standards of care Federal and state statutes require nursing facilities to have written health care and safety policies Sources of Law Statutes are laws created by legislation and are enacted at the federal and state level Health Insurance Portability and Accountability Act of 1996 (HIPAA) In some states failure by clinicians to report suspected incidents of mistreatment is a misdemeanor punishable by fine or penalty Sources of Law HIPAA Health Insurance Portability and Accountability Act 1996 Increase a person’s ability to get health care coverage when the person begins a new job Help maintain continuous health coverage when a change of job occurs Limits the use of preexisting conditions Sources of Law Every state in America has mechanisms for reporting elder mistreatment Adult Protective Services (APS) programs exist in each state Standards of care for nursing homes are based on policy stipulated in the Nursing Home Reform Act of 1987 (Omnibus Budget Reconciliation Act, 1987) Many states currently have mandatory reporting laws for elder mistreatment in which nurses & health care practitioners are required by law to report suspected cases Elder Abuse Categories of Elder Mistreatment 3 basic categories of elder mistreatment Domestic treatment - older persons home – by child, spouse, In-law) Institutional mistreatment – contractual arrangement & suffer abuse - LTC facilities, assisted living, rehabilitation or hospital Self neglect or self abuse – are mentally competent enough to understand the consequences of their own decisions – that threaten their own safety Institutional Mistreatment The types of mistreatment that occur in nursing homes likely mirror those in domestic settings Physical abuse Sexual abuse Neglect Financial abuse Psychological abuse Researchers have also speculated that shortages of staff, inadequate training of staff & staff burnout may be precipitating factors in mistreatment of nursing home residents Institutional Mistreatment Delay in reporting incidents Residents afraid of retribution Family members may fear having to find a new nursing home Staff may fear losing their jobs Facing recrimination by other staff members Want to avoid adverse publicity Assessment Ideally the older adult and any suspected abuser should be interviewed separately Maintaining a nonjudgmental approach will enable the nurse to obtain more accurate data The physical symptoms of elder mistreatment are often difficult for clinicians to discern because older adults may suffer from chronic and acute illness that mask or mimic the presence of mistreatment Assessment Their self reporting may be questioned for accuracy or they may be unable to express the mistreatment situation due to Amnesia Aphasia – total or partial loss of ability to speak ...

1. Gerontologic nursing
Chapter 3: Legal and Ethical Issues
Professional Standards
Health care providers have a general obligation to live up to
accepted or customary standards of care
Federal and state statutes require nursing facilities to have
written health care and safety policies
Sources of Law
Statutes are laws created by legislation and are enacted at the
federal and state level
Health Insurance Portability and Accountability Act of 1996
(HIPAA)
In some states failure by clinicians to report suspected incidents
of mistreatment is a misdemeanor punishable by fine or penalty
Sources of Law
HIPAA
Health Insurance Portability and Accountability Act
1996
Increase a person’s ability to get health care coverage when the
person begins a new job

2. Help maintain continuous health coverage when a change of job
occurs
Limits the use of preexisting conditions
Sources of Law
Every state in America has mechanisms for reporting elder
mistreatment
Adult Protective Services (APS) programs exist in each state
Standards of care for nursing homes are based on policy
stipulated in the Nursing Home Reform Act of 1987 (Omnibus
Budget Reconciliation Act, 1987)
Many states currently have mandatory reporting laws for elder
mistreatment in which nurses & health care practitioners are
required by law to report suspected cases
Elder Abuse
Categories of Elder Mistreatment
3 basic categories of elder mistreatment
Domestic treatment - older persons home – by child, spouse,
In-law)
Institutional mistreatment – contractual arrangement & suffer
abuse - LTC facilities, assisted living, rehabilitation or hospital
Self neglect or self abuse – are mentally competent enough to

3. understand the consequences of their own decisions – that
threaten their own safety
Institutional Mistreatment
The types of mistreatment that occur in nursing homes likely
mirror those in domestic settings
Physical abuse
Sexual abuse
Neglect
Financial abuse
Psychological abuse
Researchers have also speculated that shortages of staff,
inadequate training of staff & staff burnout may be precipitating
factors in mistreatment of nursing home residents
Institutional Mistreatment
Delay in reporting incidents
Residents afraid of retribution
Family members may fear having to find a new nursing home
Staff may fear losing their jobs
Facing recrimination by other staff members
Want to avoid adverse publicity
Assessment
Ideally the older adult and any suspected abuser should be
interviewed separately
Maintaining a nonjudgmental approach will enable the nurse to

4. obtain more accurate data
The physical symptoms of elder mistreatment are often difficult
for clinicians to discern because older adults may suffer from
chronic and acute illness that mask or mimic the presence of
mistreatment
Assessment
Their self reporting may be questioned for accuracy or they may
be unable to express the mistreatment situation due to
Amnesia
Aphasia – total or partial loss of ability to speak or understand
language
Agnosia – inability to recognize common people and things
Apraxia – inability to perform simple task
It is often difficult to determine whether the older adult’s
worsening physical condition is a result of the natural
progression of illness or mistreatment
Because some frail older individuals are prone to underlying
conditions that give rise to trauma, such as instability of poor
gait and poor vision resulting in falls, it may be difficult to
differentiate accidental from willful injuries
Types of Elder Mistreatment
Physical abuse
Psychological / emotional abuse
Sexual abuse
Financial exploitation
Caregiver neglect
Self neglect

5. Abandonment
Institutional mistreatment
Physical Abuse
Intentional infliction of physical injury or pain
Hitting
Shaking
Pushing
Improper use of physical
restraints
Signs & symptoms
Bruises
Black eye
Bone fractures
Injuries in various stages of healing
Reports of being hit or mistreated
Psychological / Emotional Abuse
Infliction of anguish, pain or distress
Yelling / verbal attacks
Swearing
Name calling
Belittling
Signs & symptoms
Emotional upset
Agitation
Extreme with drawl

6. Sexual Abuse
Any form of nonconsensual sexual intimacy
Rape
Molestation
Sexual harassment
Signs & symptoms
Genital bruising
Unexplained sexually transmitted disease
Financial Exploitation
Taking advantage of an older person for monetary or personal
benefit
Unexplained monetary expenditures
Lack of money for personal necessities
Theft
Fraud
Signs & symptoms
Unexplained inability to pay bills
Inability to purchase necessity items such as food

7. Caregiver Neglect
Intentional (active) or unintentional (passive) failure to meet
needs necessary for elder’s physical & mental well being
Failure to provide adequate food, clothing, shelter, medical
care, hygiene or social stimulation
Signs & symptoms
Dehydration
Malnutrition
Unattended or untreated health problems
Listlessness
Decubitus ulcers
Urine burns
History of being left alone
Self Neglect
Personal disregard or inability to perform self care
Poor hygiene
Unkempt home environment
Signs & symptoms
Malnutrition
Fungal skin & nail infection
Insect & rodent infestation in the home
Abandonment
Desertion or willful forsaking of an elder
Dropping off an elder adult in the emergency department
Desertion

8. Signs & symptoms
An older adult left inappropriately alone
Institutional Mistreatment
When older adult has a contractual arrangement & suffers abuse
or neglect
May be any combination of the afore mentioned
Signs & symptoms
Can be any of the signs & symptoms of the other examples of
abuse
Characteristics of Older Adults at Risk
Difficult to obtain
Several characteristics are more common among victims
Sex
Age
Race
Low socioeconomic status
Low educational levels
Impaired functional or cognitive status
History of domestic violence
Stressful events
Depression
Interventions
Health care workers must be aware of local elder mistreatment

9. reporting laws in their state
Many states have mandatory reporting laws & health care
professionals must report suspected cases
In cases were abuse is suspected an older adult may benefit
from a hospital admission to allow the healthcare team to
carefully assess & formulate a plan of care
Documentation
Excellent documentation is extremely important in elder
mistreatment cases
Objective documentation
Unbiased manner
Physical indicators that are clearly documented will assist in
discussing & planning goals
Photo documentation is especially warranted in cases where
there is evidence of physical or sexual abuse
Residents Bill of Rights
Most facilities have developed a contract for new residents to
sign at the time of admission
Called admission agreement
This agreement sets forth the rights, obligations and
expectations of each party

10. It is a way to inform residents of a facility’s rules, regulations
and philosophy of care
See Box 3 – 1 on page 37 “Residents Bill of Rights”
Unnecessary Drug Use & Chemical & Physical Restraints
The OBRA requires that nursing facility residents be free of
unnecessary drugs of all types, chemical restraints and physical
restraints
Chemical restraints
Drugs that are used to limit or inhibit specific behaviors or
movements
Physical restraints
Are appliances that inhibit free physical movement
Limb, vest, waist
Wheelchairs, geriatric chairs & side rails may also be restraints
Unnecessary Drug Use & Chemical & Physical Restraints
The nurse must carefully document the behavior or condition
that led to the order for a restraint
Residents receiving antipsychotic drugs must have an indication
for the use of the drug
Reasons must be documented in the physician’s order and chart
/ care plan
Advanced Medical Directives
Documents that permit people to set forth in writing their
wishes and preferences regarding health care

11. Used to indicate their decisions if the time should come when
they are unable to speak for themselves
An advance directive is not operative until the patient is no
longer capable of decision making
Living Wills
Are intended to provide written expressions of a patient’s
wishes regarding the use of medical treatments in the event of a
terminal illness or condition
The patient’s wishes regarding the withholding or with drawl of
life support
Living Will
Not effective until:
The attending physician has the document and the patient has
been determined to be incompetent
The physician has determined the patient has a terminal
condition or a condition such that any therapy provided would
only prolong dying
The physician has written the appropriate orders in the medical
record
Durable or General Power of Attorney
May designate someone else to make health care decisions at a
time in the future when they may be rendered incompetent

12. The role of the designated surrogate in this situation is to make
the decisions that most closely align with the patient’s wishes,
desires and values
Conflicts
Families may disagree with the directives of a family member
Often family members express the desire to have more care than
is requested by a patient
The law upholds the expressed desires of a patient over those of
the family
But families may try to exert influence to bring about a decisi on
that is sometimes contrary to the patient’s expressed wishes
POLST
Physician Orders for Life Sustaining Treatment
Process of communicating health care wishes during a medical
crisis or decline in health
Include:
Cardiopulmonary resuscitation (CPR)
Medical interventions
Artificially administered nutrition
See Table 3.1 on page 42
See Figure 3.2 on page 42
PSDA
Patient Self-Determination Act

13. Came into effect 12/1/1991
To ensure that patients are given information about the extent to
which their rights are protected under state law
Requires hospitals, nursing facilities and other health care
providers who receive federal funds such as Medicare or
Medicaid to give patients written information explaining their
legal options for refusing or accepting treatment should they
become incapacitated
Scenario #1: Abuse
• Mr. CO is a 75, year old male. He was admitted to your unit
with Pulmonary Fibrosis. As you are walking towards his room
to administer medications you hear his son say to him in a nasty
tone of voice: “Stop being so stubborn. I need you to give me
access to your bank accounts. You’re going to die alone unless
you start cooperating”. As you enter he room, the son leaves
quickly and you notice the patient has tears in his eyes. You ask
“Is everything okay?” Mr. CO shakes his head yes, but remains
nonverbal and does not make eye contact. You administer his
medications and leave the room.
Directions:
Part 1:
•The original post must be at least 200 – 300 words in length
•What types of elder abuse did you notice in the scenario? (give
examples and explain)
•What signs, (in the scenario) if any suggest that the nurse
should ask some follow up questions?
•As a nurse in this scenario what is your next action?
•How can older adults protect themselves from ever becoming
victims of abuse or mistreatment?
Scenario #2

14. You are viewing social media at home when you notice one of
your coworker’s post on Facebook. The post is complaining
about an elderly patient on your unit at work. The post reveals
that the patient has Alzheimer’s disease and is “crazy” and your
coworker states “I can’t wait until she is transferred out of here
and back to Comfort Care Homes. After this shift, you will find
me at the bar, line them up, I will need it.” Additionally, the
coworker’s full name, occupation and employer are listed on
their “about me” page.
Respond with atleast 100 words not more than 150 words
1. What would you do regarding this posting? Explain clearly
what you would do and why.