The Administrator investigated Charlie’s work history and the manner in which he was hired. This is what she discovered:

• He only applied for the midnight shift and preferred to work in the memory care unit.
• He boasted about his specialized training in managing physically aggressive residents, and how social workers and nurses were “in awe of his unique ability”.
• He could start immediately and liked to work weekends and holidays.
• He worked at (5) nursing homes during the past (3) years.
• He recently moved from another state where he also worked as a CNA.
• He was “a couple of credits short of receiving a Master’s degree in Psychology”.
• Several sections of his employment application were left blank, including the names of several supervisors and reasons for separation.
• He did not sign the reference release form to contact his last employer.
• He was articulate, very restless, and avoided eye contact during the interview. He repeatedly stated: “residents love me.”
• He was reluctant to discuss past employers, and could not recall the name of his last supervisor, but repeatedly stated: “trust me - my references are impeccable”.
• He passed criminal background and CNA registry checks in this state.
• He was only interviewed by the Staffing Coordinator, a former CNA with no college education or employee recruitment training. The interview lasted about (10) minutes.
• The Staffing Coordinator was more preoccupied with expediting Charlie’s criminal background and registry checks than obtaining employment references and scheduling additional interviews. This rush to hire him was apparently driven by high CNA turnover, significant dependency on nursing personnel agencies, daily cost containment pressure from the corporate office, and qualifying for her monthly performance bonus.
• The Staffing Coordinator heavily relied on a “personal” reference to vouch for Charlie’s moral character, which turned out to be his wife using her maiden name.
• Dates of hire/separation were not confirmed with his last employer, where he resigned without notice after becoming the subject of an internal investigation.
• Two of his last five employers checked “no” on his reference release form in response to the question “eligible for rehire”. These forms were routed after his termination.
• He cleverly concealed the existence a former employer by altering hire/separation dates of (2) other employers on his application.
• He received a “letter of reprimand” from licensing authorities in another state for unspecified conduct. Although he identified this employer on his application, the Staffing Coordinator never checked the CNA registry in that state.

The Administrator also investigated “rumors” of unusual resident activity in the memory care unit since Charlie arrived. This is what she learned:

• (2) Female residents became very withdrawn and lost a significant amount of weight.
• (1) Female resident displays fearful body language whenever staff enters her room.
• (3) Female residents are very combative with staff during ADL’s.
• (2) Female residents sustained “unexplained” bruises on their breasts, upper arms, and shoulders. Most of this trauma was discovered during weekends or Mondays. However, these incidents were not investigated despite several family complaints.
• Memory unit CNA’s disregarded unusual comments by female residents such as: “he’s a bad boy”, “I love him”, and “will he sleep with me tonight”.

Pearl was examined at a local hospital to rule out sexual assault and did not return to the facility. The incident triggered a spiraling mental and physical decline that culminated with her death. Charlie was suspended and later terminated for “falsifying his employment application”. Although he was arrested the following day, criminal charges were eventually dropped by the Prosecutor’s Office. He continues to work as a CNA because state licensing authorities never investigated the incident.

General Discussion

WELL KNOWN INDUSTRY HAZARD: Resident abuse, including sexual abuse, is a widely recognized hazard in nursing homes, assisted living facilities, group homes, and home health care. This hazard is evident by mandatory criminal background/credentialing checks, vulnerable adult laws/regulations, resident abuse hotlines and state investigative agencies, Ombudsman and advocacy programs, mandatory resident abuse in-service education, resident rights statutes, consumer publications, intense public scrutiny, and countless highly publicized incidents.

ABUSE VERSUS ASSAULT: Committing resident “abuse” represents a lower threshold of misconduct and punitive consequences than crimes such as “physical or sexual assault”. However, a resident experiences the same pain and trauma whether their abuser is convicted of a crime, or loses their privileges to practice, or loses their job. Therefore, heavily scrutinizing a caregiver’s work history and moral character is the only responsible approach to identify “abusive conduct”, which must be the primary focus of pre-employment screening. Relying entirely on criminal background and registry checks is reckless and irresponsible.

FALSE SENSE OF SECURITY: Conducting criminal background checks and verifying the status of state licenses, certifications, etc., while essential in the screening of prospective caregivers, is not adequate to detect resident abusers. There are countless predators like Charlie that travel from facility to facility and never lose their privileges to practice or are convicted of a crime. Although some are arrested, investigated by state agencies, appear before licensing boards, and are subject to internal investigations, very few face punitive consequences that establish a public record. It is important to recognize that “accused” and “suspected” abusers evade detection during the pre-employment screening process when their conduct is treated as follows:

1. LAW ENFORCEMENT AGENCIES conclude that the conduct of the alleged abuser is not worthy of prosecution due to lack of physical evidence, they are uncooperative or evasive, claims of consensual sex, or the testimony of the victim (resident) is not credible due to a mental/cognitive impairment.
2. STATE LICENSING AUTHORITIES defer investigative authority to law enforcement agencies to avoid conflictive involvement, and therefore take no action until the criminal investigation has concluded. Unfortunately, many licensing agencies never conduct separate investigations due to protracted criminal investigations where no arrest is made, or the assumption that they will reach the same conclusions. When licensing authorities are engaged, alleged abusers are afforded a bureaucratic hearing process where their right to practice their profession is often more protected than the rights of the resident(s) they allegedly abused. Consequently, these agencies conclude that there is insufficient evidence to revoke their license/certification or apply disciplinary action.
3. FACILITY OFFICIALS “conceal” the identity of alleged abusers by:
   • Failing to confront allegations of resident abuse.
   • Failing to notify state agencies of resident abuse allegations in accordance with mandatory reporting requirements, whether by oversight or conscious disregard.
   • Using generic or unrelated work rule violations such as “unsatisfactory performance”, or “excessive absenteeism” to immediately terminate or quickly force out alleged abusers rather than investigate their conduct.
   • Misrepresenting the termination of abusers by using generic work rule violations that do not contain accusatory terms like “resident mistreatment”, “neglect” or “abuse”, despite testimony/investigative findings that substantiate this conduct. Although this practice may protect the facility from liability, it unleashes these predators back to the unsuspecting public and allows the cycle of resident abuse to continue.
   • Conducting swift internal investigations that exonerate the facility and its staff from allegations of resident abuse by spinning and/or suppressing the facts using regulatory doctrines such as “unavoidable harm” to rationalize their findings. The objective of this practice is to discourage state agencies from conducting onsite regulatory surveys by creating the false impression that facilities acted properly.

RUSH TO HIRE: Some facilities relax their hiring standards despite the high profile nature of resident abuse in institutional care settings. This failure is due to cost saving policies, chronic caregiver staffing problems arising from high absenteeism and turnover rates, defective operational models, failure to comply with internal policies/procedures, unqualified employee recruitment staff, insufficient recruitment training, and absentee management.

NO EXCEPTIONS: The employment history and moral character of employees, contract staff, or any individuals who provide resident care and services, must be subject to the same scrutiny “before” they work at your facility. Unfortunately, this standard is sometimes relaxed for:

• Rehired employees
• Relatives or acquaintances of employees
• Licensed staff, including Nurses, Social Workers, and Therapists
• Support departments, i.e., activities, housekeeping, laundry, dietary, maintenance, transportation staff, and security
• Volunteers
• Nursing agency staff (pool), i.e., Nurses, CNA’s
• Private duty attendants/sitters

Under state and federal laws/regulations, the duty of a facility to protect its residents from abusers is not relaxed or dismissed when it relies on a third party to screen, hire, train, schedule, and furnish individual(s) who commit abusive acts.

RECRUITING IS NOT A NATURAL TALENT: Just because someone is a department manager, has attended nursing school, has an undergraduate degree, or is a seasoned employee, does not mean that they are qualified to perform employee recruitment activities. In particular, successful interviews result from effective training programs and proven recruitment systems.

ROGUE EMPLOYEE: When confronted with allegations of resident abuse, most facilities contend that physical, sexual, and violent acts are unforeseeable and outside the scope of the abuser’s employment. However, this defense lacks credibility when there is evidence of: (1) negligent hire, and/or (2) negligent retention, and/or (3) negligent supervision of the abuser in question.

SELF-FULFILLING PROPHESY: If you or your staff believe that detecting resident abusers during the pre-employment screening process is unrealistic because former employers only provide dates of hire/separation, researching work histories is laborious and costly, finding staff with a strong work ethic and good moral character is a roll of the dice, and many applicants have mastered the art of interviewing, then it is only a matter of time before one of these predators strikes at your facility. The best opportunity to prevent resident abuse is before a predator becomes your employee.

Would you, without hesitation, place the safety and wellbeing of your parent/grandparent in the hands of the caregiver you just interviewed? There can be no lesser standard.

TEST YOUR INSIGHT: How many hiring “red flags” were raised before Charlie was offered a job? Hint: There are more than (10).

NOTE: The incident depicted in this article is fictitious. Any similarity to any person(s) living or dead is merely coincidental.

ABOUT THE AUTHOR:

Lance Youles has consulted in over (40) states regarding eldercare abuse and neglect. He can be reached at (517) 548-1228 or at lancenpat@aol.com

Note: This article appeared on June 8, 2011 in Advance for Long-Term Care Management

A vigilant daughter stands guard at the doorway of her mother’s room. A call-light globe flashes overhead in unison with a faint audible signal from a distant nurse’s station. In the shadows of a quilt covered bed, a resident sits motionless trying to suppress her aching bladder. Minutes seem like hours in a desperate race to avoid a shameful episode of incontinence. Convinced she must abandon her lookout post after twenty five minutes, the frustrated daughter contemplates more assertive options. Acting from instinctive devotion, she wheels her mother into a small adjacent bathroom. As she positions herself for a toilet transfer, her fragile back condition registers and she draws back in a head-held moment of tearful defeat. She quickly collects herself and applies a reassuring kiss to her mother’s cheek. “It’s okay dear” the mother tells the daughter, “I can wait until help arrives”. Determination turns to anger as the daughter swiftly departs the bathroom on a mission to kidnap a caregiver.

The annoying call-light beacon grows louder as the daughter draws closer to the Nurse’s Station. However, the station is vacant when she arrives. She glances into an adjacent day room and notices a Nurse’s Aide standing alone in front of a television eating a candy bar. The breathless daughter enters the room and announces her presence with a noisy “sigh”. Relief is finally on the way Mom, she mutters to herself. The startled Nurse’s Aide turns around abruptly like a child caught doing something wrong. She stares at the daughter for a moment with contempt wondering what the abrupt intrusion is about. “My mother needs assistance in the bathroom, can you please help her”, the daughter asks in earnest. The Aide looks down at the floor with a solemn facial expression, closes her eyes, and slowly nods her head up and down. “Show me where” the Aide softly mutters to the daughter.

The Nurse’s Aide follows the daughter, but immediately reverses her course when she discovers the resident’s identity. Sensing the footsteps behind her have stopped, the confused daughter looks back. To her dismay, the Aide is returning to the vacant day room. The daughter pursues the retreating Aide at a frantic pace until she is close enough to call out. “Hey” she screams, “what are you doing?” The Nurse’s Aide turns slowly contemplating her next evasive move. She tried the cold shoulder routine, but to no avail. The time for subtle diplomacy was over she concluded. Rolling her eyes with hands firmly planted on her hips, the Nurse’s Aide sternly informs the daughter, “She’s not my resident – leave me alone!” Shocked and speechless, the daughter watches the Aide walking away flinging her arms upward mumbling something about short staffing.

How could a person be so cruel and cold-hearted, the daughter asked herself? What did the Nurse’s Aide mean by “not my resident”? Did my plea for assistance violate some caregiver doctrine I should be aware of, she asked herself? Surely, Nurse’s Aides do not limit their contributions and compassion to the residents listed on their assignment sheets, she reasoned. Her confidence in the staff was shaken. For the first time, she feared for her mother’s wellbeing.

Frustrated but not defeated, the daughter hurries back to her mother’s room. She was determined to end this nightmare even it meant reinjuring her back. She was nearing her mother’s room when a medicine cart suddenly blocked her path. “Excuse me” said a smiling Nurse, as she maneuvered the boxy cart into the hallway. The daughter stared at the Nurse like she saw a ghost. How ironic she thought, I cannot find a caregiver when I search the building, but I nearly collide with a Nurse outside my mother’s room. “Can you ask an Aide to help my mother in the bathroom” sputters the exhausted daughter. “I can help” the Nurse responds, as she parks the cart in the hallway and locks the drawers. She quickly proceeds to the bathroom and within seconds the torturous ordeal is over. “Thank you dear, you saved me from a terrible embarrassment”, the resident exclaimed! “You are welcome” the Nurse replied, as she placed her reassuring hand on the resident’s shoulder. “I am sorry you waited so long.”

Standing next to the Nurse outside the bathroom, the daughter asks “is my mother one of your residents?” “Why yes” the puzzled Nurse replies, “why do you ask?” “You were very eager to help me, so I assumed my mother was assigned to you. I tried to get help from an Aide, but my mother was not assigned to her. She said my mother was not one of her residents”. “That attitude is inexcusable, replied the angry-voiced Nurse. Daily assignments are designed to focus attention on a particular group of residents, but never to ration our care and services. Aides are expected to assist every resident they encounter who requires immediate attention. Unfortunately, that expectation is difficult to enforce. Every resident in this facility is my resident! I hate that awful comment,” she continued. “That Aide would never say that to me.”

The daughter was comforted by the Nurse’s timely intervention, but she worried about next time her mother needed assistance. What will happen to her when I am not here she thought? Sensing the daughter’s anxiety had not passed, the Nurse offered some reassuring words. “This deplorable conduct rarely occurs at this facility”, she explained. “Most of our Aides are very caring and attentive. Unfortunately, the negligent conduct of one misguided employee can overshadow countless employee contributions. It takes a very special person to meet the physical and emotional needs of nursing home residents, and the true measure of that devotion is always revealed over time. Some Nurse’s Aides begin their career with noble motives. Unfortunately, personal problems can drain their spirit and the “I’m going to make a difference” crusade succumbs to inanimate/assembly-line resident care. Once that inspiration is lost, those Aides are no longer worthy of the privilege to work here. I treat my job as a ministry and so do most of my coworkers, the Nurse proudly confessed. There are rewards in life that are far greater than money and praise, but you must have conviction of the heart to receive them. I would choose this facility if my mother or father needed a nursing home,” she concluded. The daughter hugged the Nurse in a tearful display of gratitude. She could go home now; her mother was in very good hands.

Lance & Associates 2012 ® All Rights Reserved
Staff Education Library

They sat silently in the old Dodge pickup truck staring at the front door of the nursing home. A frail 79-year-old man slowly rolled down the passenger-side window and lit a cigarette. With a long sigh and solemn expression he turned to his son, paused for a moment, and stated: “I faced brutal machinegun fire on Saipan and Okinawa and witnessed things during my 40 years as a Cop that no one should see, but this place scares me,” pointing to the facility. The father tried to conceal his trembling left hand by wedging it tightly between his legs. However, the Son quickly looked away as though he didn’t notice this embarrassing moment. The Son shut off the idling engine, unfastened his seatbelt, slowly turned to his father and stated: “Dad, we can’t let your terrible experience at the hospital discourage you from walking again. Those nurses should be ashamed of themselves for the negligent treatment you received, and I find it hard to believe that they lost your Marine Corps ring. Like I keep saying … if you want good bedside nursing care from caregivers who treat you like a person instead of a disease, then only a nursing home will do.” The old man nodded his head up and down and mustered a smile. The son opened his door, stepped out, and stood facing his father motioning his hand toward the nursing home stating: “let’s go Gunny; it’s time to get some rehab!”

Lance & Associates 2012 ® All Rights Reserved
Staff Education Library