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ELDERLY PATIENT NEGLECT IN NURSING HOMES

Elderly Patient Neglect in Nursing Homes

Victoria Johnson

James Madison University

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ELDERLY PATIENT NEGLECT IN NURSING HOMES

Introduction

The Center for Disease Control and Prevention (2016) reports that in the United States,

approximately 1.4 million adults live in nursing homes and long term facilities with about 40%

of all adults expected to enter a facility at one point in their lives. The population living in these

communities are often at increased risk for abuse and neglect due to the vulnerability and

dependency of care that they require. Many residents in nursing homes are unable to report

incidents of abuse or neglect because of limitations related to cognitive functioning and physical

abilities due to several chronic diseases. Maltreatment in residents is most commonly associated

with physical abuse such as hitting, yelling or threatening the individual. Recently, patient

neglect has become more prevalent and has prompted more attention as an issue in these health

care settings. Neglect is another form of abuse that relates to failure to act to meet the needs of

the dependent rather than the intent to harm a patient. Regardless of the absence of purpose to

harm, both acts can lead to injury or harm which can result in suffering, pain or impairment.

Approximately 44 percent of nursing home residents reported that they had been abused during

their residency and nearly 95 percent had seen another resident neglected (Hawes, 2003).

Background

My ethical dilemma experience occurred during my first clinical rotation in a retirement

community caring for a patient with dementia. The individual was a high fall risk due to a hip

replacement which made him wheelchair dependent and a one person assist. Due to his cognitive

functioning, he was alert but greatly disoriented to his surroundings. He would become quickly

agitated during assessments and in moments of confusion he would attempt to stand up out of his

chair to leave the facility. The CNA’s often kept an alarm on his wheelchair and had him in the
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ELDERLY PATIENT NEGLECT IN NURSING HOMES

lobby for close monitoring due his elopement risk. He required constant reminders to remain in

his chair and the importance of doing so to avoid falls which could potentially prolong his stay.

During the afternoon, he was having trouble with constipation and with multiple attempts

he was unable to pass a bowel movement. The CNA explained numerous times that he was given

his Miralax and to wait for the medicine to take effect. The patient was using his call bell every

other five minutes, asking the CNA to help him to the bathroom. After getting him to the toilet

three times within twenty minutes with nothing passing the CNA chose to start ignoring the call

bell. She was only prompted to go into the room when his chair alarm would go off. After

multiple alarms were set off, the CNA turned to me and told me “he has the right to fall”. When

the next alarm went off the CNA responded slowly. In the room we found the patient out of his

chair attempting to get on the toilet about to fall. Luckily, we were able to support him onto the

toilet avoiding a fall. I then decided to spend the rest of my clinical day in his room, assisting

him to the bathroom and educating him on his medications, the rationale of not getting an enema

and the importance of safety precautions. If I could go back to the situation I would do the same

thing but stay in the room with him earlier and encourage him to wait and assist him with

scheduled toileting.

This situation caused moral distress within me because I knew that to ensure safety for

this patient, someone had to be in the room monitoring and assisting him. In his particular

situation I believe it was not a case of him being noncompliant but due to his dementia he

genuinely did not understand the reasoning behind the approach the CNA was suggesting. As a

new student in a healthcare setting I felt an obligation to help the facility with other patients and

to trust the professional in what she was telling me instead of following what my instincts were

telling me was the right thing to do.

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ELDERLY PATIENT NEGLECT IN NURSING HOMES

Methods

When faced with an ethical dilemma it is critical for one to analyze the issue in order to

understand the situation before making a decision. The Eight Key Questions is an ethical

framework designed by James Madison University that consists of components that are based on

outcomes, duties and virtues that can be utilized to help with approaching and reasoning

necessary to come to a decision (The Madison Collaborative, 2013). The key questions address

fairness, outcomes, responsibilities, character, liberty, empathy, authority and rights.

To treat the patient fairly we must view the patient as equal to all others. The patient does

acquire further accommodation than others but deserves the same amount of respect and care as

others. As a nurse our priority is to provide care to ensure the best outcome for the patient.

Assisting his requests will avoid him potentially falling and causing further injury which will

prolong his rehab or cause another unnecessary harmful outcome. In this situation, my

obligation was to take action to the patient requests and to ignore alarms and call bells would be

neglecting the patient. My personal values impact my role as a nurse whilst providing care and

making decisions for patients. If those are in jeopardy, I must question and acknowledge my

emotions in order to remain ethical and professional as a caregiver. When considering liberty in

the healthcare field it is imperative to maintain the patient’s autonomy. As nurses we are able to

do so by acting as their advocate, such as questioning the CNA’s judgement to ignore their call

bell. To be empathetic would be to view yourself in the patient’s perspective. If I was the patient

I would hope that those taking care of me would respect me enough to carry out my wishes

regardless if my requests seem “time consuming, unnecessary or difficult”.

As a JMU Nursing student we are expected to hold true to certain expectations and

standards when in a clinical setting by respecting the site, their employees and patients. Even
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ELDERLY PATIENT NEGLECT IN NURSING HOMES

though the CNA is technically my authority, I believe her commands were not consistent with

the other key questions. By not questioning authority, I was not taking into consideration the

potential harm for the patient but also the consequences of the site, myself and the employee.

Finally, humans rights must be respected and honored, even as basic as the right to use the

restroom. The patient is dependent on others to help him and by not assisting him that is taking

away his rights at a time when he is most vulnerable and in need.

The American Nurses Association’s Code of Ethics states that nurses must promote,

advocate for and strive to protect the health, safety and rights of the patient (ANA, 2015). To do

so, one must address impaired practice and act on questionable practice. Before reporting the

CNA for neglect, an action one could take would be to enquire the reasoning behind her

approach and suggesting an alternative that would be better suited for the situation. If the CNA

were to deny taking a different approach, that is when it would be appropriate to either reach out

to an instructor, another CNA or a nurse to report their actions. This approach to patient care is

neglectful and should be addressed to avoid continuing practice that puts other patients at risk.

Conclusion

When caring for those in long term facilities it is important to acknowledge that this

specific population is typically more dependent and vulnerable than others you may encounter in

practice. What I learned by reflecting on this dilemma is to never disregard behavior or care that

is questionable to the safety of a patient or others. I would have done exactly what I did but

initially when the situation presented itself instead of waiting until the patient was in a

threatening position. By taking the time to reason through different approaches one is able to

come to ethical decisions which in turn will decrease distress of the care provider, resolve the

issue and result in better outcomes for patients.

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ELDERLY PATIENT NEGLECT IN NURSING HOMES

References

American Nurses Association,. (2015). Code of ethics for nurses with interpretive statements.

Washington, DC: American Nurses Association, 2015. Reprinted with permission.

Retrieved from

http://www.bc.edu/content/dam/files/schools/son/pdf2/ANA%20code%20of%20ethics.pd

Hawes C. (2003). Elder Abuse in Residential Long-Term Care Settings: What Is Known and

What Information Is Needed?. Elder Mistreatment: Abuse, Neglect, and Exploitation in

an Aging America. Washington (DC): National Academies Press (US); 2003. 14.

Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK98786/.

The Madison Collaborative. (2013). The Eight Key Questions Handbook. Retrieved from

https://www.jmu.edu/mc/Docs/131101%208KQ%20Handout%20Revision.pdf.

Harris-Kojetin L, Sengupta M, Park-Lee E, et al. Long-term care providers and services users in

the United States: Data from the National Study of Long-Term Care Providers,

2013–2014. National Center for Health Statistics. Vital Health Stat 3(38). 2016.

Retrieved from https://www.cdc.gov/nchs/fastats/nursing-home-care.htm.