Adequate healthcare is a principle priority for many Americans and in the treatment of their loved ones. Many who are unable to take care of a loved one full time, choose a nursing home in hopes of providing better assistance and care. Though the stressful question lies, as to whether these homes are treating their patients ethically and improving rather than demeaning their quality of life. While the burden of care is taken off of the family, other issues arise when elderly loved ones are unable to notify or articulate to their families that they are experiencing mistreatment or abuse. Since the creation of nursing homes, there has been concerns of abuse with many cases remaining a secret. Fortunately, it has become better known to the public in recent years, leading to countless investigations and shutdowns of specific homes. Research studies have proven that patients with similar illnesses and diseases can be subject to contrasting abuses.  For the purpose of wanting the best for each elderly member of society, the risks drastically outweigh the benefits of sending one into a nursing home. The different forms of abuse highlight the maltreatment any patient could encounter including, but not limited to physical, sexual, and verbal abuse. 

To reflect on the start of this industry, nursing homes originated in 1935 with the enactment of the Social Security Act. The SSA provided federal subsidies for the financially unstable elderly, though this “law specifically prohibits making these payments to anyone living in public institutions (poor houses, which had become known for their terrible living conditions), thus spawning the creation of the private nursing home industry” (Kaiser Family Foundation). In 1935, the national survey of nursing homes was not collected and the federal government had scarce involvement. During this time period, many family members took the role of a nurse or assistant and took care of elderly members within their own home. Researchers also found that many workers were not legally certified to provide care yet still remained employed. The United States government became a bit more involved with “the first national survey of nursing homes in 1954, there were 9,000 homes classified as skilled nursing or personal care homes” (Improving the Quality of Care in Nursing Homes). 

With substantial growth in the nursing home industry, issues of abuse and fraud became prevalent, which caused amendments to be made in 1967. These amendments gave state governments the responsibility and control over nursing home administrators.  With time, many other amendments are put into place, one being “The Nursing Home Reform Act imposes quality standards for Medicare and Medicaid-certified nursing homes in response to well-documented quality issues facing seniors in nursing homes” passed in 1987 (Kaiser Family Foundation). With each amendment made, it becomes evident that there is a never-ending cycle of issues, with each solved problem within nursing homes, another arises. 

In quickly moving through history, a total of 16,000 certified nursing homes were accounted for. These homes care for about 1.4 million elderlies with 72% being women; with each visit ranging from “just a few days while they rehabilitate from a hospital stay but often for years, until they die” (Comarow). 

The vast difference in stay times in nursing homes are largely dependent on why a patient has entered a home. As previously stated, some patients need specific assistance after recovering from a major surgery, most commonly, hip or knee replacements. The reason for these short stays are to properly rehabilitate the body before going back to his or her daily life. Additionally, these patients typically do not have permanent disabilities that would negatively affect their quality of life or prohibit them from performing daily tasks. 

The majority of patients do enter these homes because they have physical problems meaning they cannot perform activities of daily living on their own. The most common activities include “eating, bathing, dressing, toileting, transferring (walking) and continence” (Anspach). On average, patients struggle with performing at least three of the daily tasks. Patients with physical needs would expect to have a nurse that would provide assistance in performing these tasks. 

Another reason for having a family member enter a nursing home is due to psychological deficits or mental illness. In these cases, patients will likely be unable to perform one or more of the activities of daily living, in addition the mental condition. Conditions range from behavioral issues such as “verbal and physical abuse, acting inappropriately in public, resisting necessary care, and wandering” to more serious cases of Dementia where memory and judgment is extremely clouded (Nursing Homes: Basic Facts and Information). Alzheimer’s is a form of Dementia and includes protein deposits and entanglements within the brain, which cause depression, confusion, and diminishes memory and ability to perform basic activities of life. These patients require a substantial amount of care and supervision as they can accidentally cause serious harm to his or herself or others. 

Moreover, when a patient requires acute supervision and attention, a professional caregiver is necessary along with significant time dedication. Some professionals working within nursing homes are registered nurses, licensed practical nurses, certified nursing assistants, and physical therapists; each having different licenses and certifications. Certified Nursing Assistants work the most with patients yet have the least educational and experience requirements in the field. These requirements include a high school diploma/ GED and to complete a CNA certification program which ranges from six to twelve weeks. These nursing assistants are assigned to multiple patients per day, expected to perform the activities of daily living, and respond to specific needs of each patient. This job assignment presents the issue of having a lowly qualified caregiver attend to an extensive list of patients, where care time is often cut short due to the need to get to each patient. Statistics have shown that “many nursing homes operated at 100% occupancy” which puts nurses in constant demand and has been proven to lessen the quality of care of each patient (Castle). 

A further alarming statistic is that a registered nurse must go through the most training and certifications but by federal law, has to spend little time in the nursing home. The required time of stay is for eight hours each day, which leaves practical nurses to be the most qualified caregiver for the other sixteen hours. There are endless cases documented of underqualified nurses having to take of patients because a registered nurse was not on a duty, which often results in needless tragedies and medical mistakes. 

Similar to many other healthcare industries, the quality of nursing home caregivers and treatment is directly dependent on what that patient is paying to reside in the home. While nursing homes were originally created to serve as a home for those who cannot properly take care of him or herself, the focus has turned to financial gain. For profit nursing homes are motivated on the mentality that they “will produce quantity and quality of care up to the point where the marginal cost of improvement equals the marginal financial gain from doing so.” (Park). Unfortunately, for there to be improvements in the quality of care, there either has to be a federal or state standard that is not met or a financial benefit to the nursing home company. When a quality of care standard is not met for a nursing home, it reflects substantial issues within that system, as national standards are extremely low. On the other hand, a nursing home with improved care, statistically has patients who are paying a higher monthly or yearly fee to reside. In either instance, the positive changes in care are for the benefit of the nursing home, to prevent shutting down or for economic gain; not for the patients. 

In studying the factors of poorly qualified nurses, low federal standards, along with economic concentrations; each have a role in creating harmful and disturbing cases of abuse. As stated previously, there are many forms of abuse a patient can be subjected to such as physical, sexual, and verbal abuse. Recent studies have also shown that, “local law enforcement officials indicated that they are seldom summoned to nursing homes to immediately investigate allegations of physical or sexual abuse” where there is time in between to obstruct evidence, creating a more substantial problem (Aronovitz 4). Again, abuse is nothing new in nursing homes, as it has been noted and had countless amendments put in place for over fifty years. While the amendments have limited some issues, there has never been a true resolution, and as history has shown, there may never be a perfect solution. 

Nevertheless, it is important to research each form of abuse and the likelihood a patient will experience it to have a better understanding of why nursing homes are dangerous places. To begin, there is a wide spectrum of acts that can be classified under physical abuse, all include force and intentions to cause harm. A few examples include, “beating, shoving, pushing, biting, slapping, shaking, burning or kicking the victim. Physical abuse can also involve using drugs inappropriately, physical punishment, force-feeding the individual and using physical restraints” (Elder Abuse Types). Many times, an elderly person is unable to report the abuse to a family member, friend, worker, or police officer and the abuse continues. Some signs that reflect physical abuse to the exterior part of the body include severe bruising, unexplained dislocations and sprains, or lacerations. A tactic used by abusive workers to cause fear and prevent a patient from exposing the abuse is not allowing visitors without a caregiver in the room. 

In recent times with the ever-improving technology, families who have suspected abuse of their loved ones have installed hidden cameras in clocks, dressers, or picture frames. What was discovered from the film footage, is horrifying. Too frequently, sons and daughters find that their parents are being forcefully thrown into bed, held down and mocked by certified nursing assistants and other caregivers. In a specific case, aired on Dr. Drew, Rose Rodriguez found that her 84-year-old mother was being poked and slapped by the man who was allegedly taking care of her. An even more unsettling truth is that his abuse was not a one-time occurrence, many nights of her being helplessly taunted was caught on camera. Surveillance cameras are a fairly recent invention, and one aspect to consider is the amount of undocumented abuse that has occurred since nursing homes began over seventy years ago.  

Overmedication is a frequent form of abuse as it is difficult for visitors or family members to notice. One of the few symptoms that could be detected is an overly relaxed or inebriated-like state where the patient does not seem concentrated on conversation. A 2010 study by the University of South Florida found that, “71 percent of Medicaid residents in Florida nursing homes were receiving a psychoactive medication-an antidepressant or anti-psychotic, say, or dementia drugs” when most patients were not diagnosed with any type of psychiatric condition (Span). Nursing homes are able to provide unnecessary medication because the majority of state laws exempt patients from mental health screenings if they are sent from a hospital. But why are these patients being overly medicated, one may wonder. Well, it revolves back to underqualified and overworked caregiving staff. Antidepressants and antipsychotics are used to sedate the elderly so less care and time has to be spent on each patient. Dr. Molinari of the University of South Florida also blames many cases of “falls, confusion and delirium, and hospitalizations” on patients being in this highly medicated state (Stan). Rather, it is believed that long term, non-drug therapy would improve behavioral issues and lessen accidents, though only twelve percent of Floridians in the study experienced this therapy. 

Similar to physical abuse, sexual abuse of the elderly has been caught on secret cameras. Sexual abuse is defined as “having non-consensual sex with an elder. Any type of sexual contact with someone who is unable to provide consent is also a form of sexual abuse” (Elder Abuse Types). Cameras have served as a private detective for many families, yet “76.2 percent of elder sexual abuse cases have at least one witness,” and too often, the witness does not come forward (Elder Sexual Abuse). Like physical abuse, there are also some signs that reflect sexual abuse has occurred such as “bruising on inner thighs or around the genital area, extreme agitation, new difficulty sitting or walking, and withdrawal from social interactions” (Elder Sexual Abuse). 

One specific case of sexual abuse was aired on WCIA News Channel in 2016, of a worker Bickford Assisted Living and Memory Care, who attempted to sexually abuse and pay others to do the same to patients. Channing Butler targeted patients with severe memory issues and planned to record others doing vile acts. Butler was previously employed at six other nursing homes and believed to have attempted similar acts, without ever being caught. He was charged with six counts of abuse related to Bickford Assisted Living but escaped investigations at other homes. This case is one of the few that actually was investigated and prosecuted, while innumerable others remain a secret. 

Lastly, verbal and emotional abuse can happen on a daily basis at nursing homes. Verbal abuse can range from “insulting the elder, engaging in verbal assaults, humiliating the elder, threatening the elder, intimidating the elder or harassment” (Understanding Elder Abuse). Emotional abuse can be nonverbal and will keep an individual away from others or prevent them from doing things they enjoy. These forms of abuse are far more difficult to discover, document, and prosecute as there are no physical signs. Verbal and emotional abuse can cause an elderly person to be in a melancholy or angered state and has decreased interactions or correspondence with others.  Social stimulation for any human is a key component to happiness and without it, mental health can rapidly decline. For instance, CNN aired a story of Lois McCallister, an Alzheimer’s patient, who complained to her family that she was a victim of verbal and physical abuse. The concerned family contacted the nursing home, and their response blamed McCallister for having a declining mental state and deemed her to have little credibility. Eventually, the caregivers who were in fact abusing McCallister were caught on camera and faced criminal charges. 

Though nursing homes have had an increasingly horrible record of abuse and maltreatment, there are patients who are properly provided for. Again, many of the homes with the best care and most professional staff, are more expensive and exclusive to live in but they do provide necessary service. A nursing home, when thoroughly researched and interviewed can be a viable option for families who cannot take care of their loved one any longer and do not want to hire a live-in aid. Knowing what questions to ask a potential nursing home and what signs to look for has potential to prevent negative events from occurring. 

The true problem is that families who are already spending extensive time caring for their loved one, should not have to spend even more time ensuring they will be safe in a nursing home. There are so many opportunities for unethical treatment to occur within these elderly homes and society needs a solution, other than hidden cameras. Like most national issues, higher standards have to be put in place on the state and national level. In the past seven years, health care reforms like the Affordable Care Act of 2010, have made efforts to improve the quality of living by creating incentives for when nursing homes make positive changes. In 2013, “The Commission on Long-Term Care issues a report to the Congress, reviewing LTSS policy and program issues” which suggest better staffing and service (Long-Term Care in the United States: A Timeline). Additionally, in 2014 and 2015, Centers for Medicare and Medicaid Services worked to improve nursing homes qualifications and how a nursing home’s performance is rated under the “Five-Star Quality Rating system” (Long-Term Care in the United States: A Timeline). These efforts definitely have the ability to change nursing homes and hopefully they will in coming years. One change that would substantially impact the quality of care would require Certified Nursing Assistants to be held to a higher level of education and experience in the field. In many cases, CNA’s are the abusers of the elderly, but with higher certifications required, the chances of abuse can be significantly lowered. 

Nursing homes, in time, could be a viable option for the elderly population, but that time is not now. As preached by George Santayana, “those who do not learn from history are doomed to repeat it” and the United States has repeatedly failed to learn from history in how to properly combat nursing home abuse. Endless cases, documented and undocumented, of physical, sexual, and verbal violence highlight how unethical these facilities are. The elderly population is too vulnerable to be put in the hands of inadequately trained nurses that are held to such low national standards. 
