definitive evidence about prevalence. There are several reasons for this. First, existing estimates are based on reports to a multiplicity of agencies, each of which uses different definitions, investigative protocols, and standards of proof. Second, research and well-established protocols are needed to distinguish incidents involving abuse and neglect from the natural consequences of multiple chronic diseases and disabilities experienced by long-term care residents. Third, there is significant underreporting by health care professionals, residents and families, and the official mechanisms for receiving formal complaints of abuse and neglect are deeply flawed.

Multiple Reporting Agencies and Differing Definitions

The chief impediment to rigorous epidemiologic research has been widely differing definitions of abuse.

Lachs and Pillemer (1995:437)

There are multiple agencies with some responsibility for investigating cases of abuse or neglect (U.S. Department of Health and Human Services, OIG, 1998, 1999b; Tatara, 1990; Hawes et al., 2001). For residents in nursing homes and residential care facilities, those agencies differ across states but typically include ombudsmen, adult protective services, the state survey agency responsible for licensing nursing homes, the state agency responsible for the operation of the nurse aide registry, Medicaid fraud units in the attorney general’s office, and professional licensing boards, such as the Board of Nursing or Boards of Nursing Home Administrators.

As a result, the data from one agency, such as the ombudsmen, should not be taken as an indicator of the amount of abuse, because “many abuse complaints are reported to other state agencies, not to the ombudsman program” (Administration on Aging, 2000). In addition, the existence of multiple reporting agencies means that data on the prevalence of abuse are often incomplete, generated using different definitions and methods of data collection (Baron and Wellty, 1996). In practice, reporting individuals and agencies use different definitions and have different standards and practices for the timing and nature of investigations and for classifying an allegation as substantiated (Hawes et al., 2001; Huber et al., 2001; U.S. Department of Health and Human Services, OIG, 1999b). For example, some of the reporting agencies, such as the Boards of Nursing, use different definitions of abuse, excluding anything that would be classified as verbal or psychological abuse, such as threats or yelling at a resident in anger (Hawes et al., 2001). Similarly, in general, ombudsmen are not held to a standard of beyond a reasonable doubt (Huber et al., 2001). However, in most states, the investigations of abuse by the nurse aide registries do adhere to the standard of beyond a reasonable doubt (Hawes et al., 2001).



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