Perpetrators of elder abuse can include family members, healthcare workers, nursing living facilities, and retirement facilities. Elder Justice Policy reports that 84% percent of Medicare claims were failed to be reported by skilled nursing facilities to state survey agencies as required by federal law and regulation. State survey agencies also fail to report claims to local law enforcement at a high rate. The ladder of mandated reporting does not stop at the agency or department you attend to, and it can typically take up to a year to get the Medicare claim on file which is not only discouraging but can be fatal to the vulnerable persons involved.

Cases involving elder abuse comprise of financial exploitation (majority of cases), physical abuse, neglect, and sexual assault. There have been several policies developed in the past decade by the Senate to better define elder abuse and neglect as prosecution has expanded due to more cases coming in. Section 2011 under the Elder Abuse Prevention and Prosecution Act defines an elder as an individual aged 60 years or older and abuse as “the knowing infliction of physical or psychological harm or the knowing deprivation of goods or services that are necessary to meet essential needs or to avoid physical or psychological harm.” Section 2011 defines neglect as “the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health or safety of an elder.”2 It also defines exploitation as “the fraudulent or otherwise illegal, unauthorized, or improper act or process of an individual, including a caregiver or fiduciary, that uses the resources of an elder for monetary or personal benefit, profit, or gain, or that results in depriving an elder of rightful access to, or use of, benefits, resources, belongings, or assets.

Over the past ten years, the defense bar and its experts have become far more adept at persuading arbitrators, judges, and juries to focus not on their facility's failings but on the elder's “pre-existing conditions” as the basis for the unfortunate medical outcome. It gives stronger argument that the treatment from these nursing facilities are improper and poorly evaluated and outweigh the complications of capacity of the adult that was abused. Typically to determine impaired decision making, capacity and competency evaluators are conducted by a multidisciplinary team to assess. From managing money to driving an automobile, the capacity to do one thing can be vast from another task. To view and understand all capacity terminology and screening procedures, please click here: Capacity Screening in Adult Protective Services: Guidance and Resources (acl.gov)

There are not easy to retrieve when needing the examinations on a timely basis for the adult and can be shortened due to the physician's or evaluator's urgency to get as many evaluations done as possible with their demand. The assessment itself has been critiqued for needing further development as there might be certain specializations to be trained in as the type of capacity or capacities have expanded to be checked as each adult has unique lifestyles. Even having the opportunity for an adult to have a capacity evaluation is limited as systemic barriers cause who has that service included in their health insurance, if the adult's history of health conditions and actions are deemed “qualified,” and possible financial and identity discrimination the adult or patient can face in healthcare overall. To be on the other side as the mandated reporter, understanding the roadblocks of that role is key as there are multiple phases when trying to communicate about the elder abuse and neglect. It can be intrusive to the family member or patient, with reasonable fear of causing uproar or even losing that relationship with the adult. The person can have a terminal illness or is dealing with cognitive issues, and the stigma they hold internally with abuse is not a one-time connection for them to accept. Here are tips for mandated reporters when aware of ongoing elder neglect and abuse:

• You can contact Adult Protective Services (APS) for the importance of documentation. A case number will be on file for your claim, and there will be a case manager that will contact you (hopefully shortly). If you are contacting law enforcement and their response is that assistance cannot be provided due to the claim seen as civil, request to speak to a sergeant and don't give up! If there is an emergency with the elder adult, immediately call 911.
• Individual reporting is intense and can come along with the worry of a subjective perspective when observing abuse. It does not have to be navigated alone. Reporting can be assisted by a team or multiple persons within the family to conclude its objective concern for the elder adult.
• The reporting of course, needs to come with definite awareness and with genuine intentions. In the state of California (add MR law here that includes protections). For the person or group who has the power of authority to take care of the adult, be ensured that the caregiver(s) and/or facilities have the tools to do their job but make the choice not to. With these injustices can include financial motivations or abuse of power.
• Keep up to date with laws and regulations of elder abuse in your local jurisdiction. Laws are always changing and new ones are being introduced by legislation. This can also be applied to Medicare policy and poorly-operated facilities under the program of Special Focus Facility (SFF).
• If seeking legal advice, talk to a local elder law or civil attorney. This can be extremely helpful in determine if your claim in criminal or civil and to assist in the next step to take for reporting.

Recommendations for the Center of Medicare and Medicaid Services have been made by advocacy groups and government agencies such as the Health and Human Services (HHS) in how to keep reporting for elder abuse with evolving improvements for Medicare-based claims to be adapted to diagnosis codes that can help further prevention of increasing rates of elder abuse in the past decade. With Medicare claims data identifying more than 30,000 incidents of potential abuse or neglect under a standard of 17 diagnostic codes from 2015-2017 along with other profounding studies, CMS has the responsibility to use this insight to prevent future elder abuse and neglect of Medicare beneficiaries.

My Family's Story

As personal disclosure, I have two very supportive and lovely grandparents that owned a cozy and beautiful home for over 20 years. I would go to their home every week growing up, being spoiled with great dinners and a nice background to play in and lounge around. At the dinner table before eating, I would help my grandma learn how to read and write in English and make puzzles together that were almost as big as me as a child. My grandpa and I would water his plants and add new ones into pots he would get from Mexico on a monthly basis. It was a home that I could call mine myself, as someone who had emotional difficulties with my parents.

Fast forward to the end of my first year in college, my parents had told me over the phone as I was heading back to Bakersfield from Los Angeles after a hefty semester, that my grandparents were going to lose their home. Usually, I talked on the phone with my grandma on a biweekly basis to check in and catch up. This was the first time I ever heard of this, and it was news told from over a couple months ago. I was in complete shock, and I drove straight to their house when first entering into town. I knew it was tremendously hard for my grandparents to discuss this openly as part of a family, seeing over the years of how much internalized stigma they carried and navigating the world as Mexican-Americans. I also knew how dreadful this was to see my grandmother having to endure this in silence.

It was to be found out that my grandfather's son from a past marriage needed money for unnecessary purposes and led to my grandfather putting out a second mortgage on his home that he could not obviously afford. He was retired, my grandmother having been a stay-at-home mother for her children since they were little, and the both of them heavily depending on social security as a source of income. This person in the family was always known to be unstable in different ways and never quite respected his father, lots of tension for a long time. My family has always been very compassionate and understanding to everyone from all walks of life, but this was something that we knew had gone too far. My grandparents had no way of retrieving their home and had to foreclose. Devastation and embarrassment is what they described to me as how they felt from the moving process. The home that my parents, siblings, and I were staying at for the past two decades is actually owned by my mom's passed father and given to my grandmother to later own (so basically, we were renting from my grandmother). This was a much smaller home, but anyone in the family can live there if needed. My grandparents ended up moving there and us renting a new home not far away. The changes we all made were positively accepted with great cooperation.

A year had passed by, and more issues came up again. My grandfather had suffered two strokes and was diagnosed with dementia. My grandmother was also showing signs of memory loss and chronic issues that took collective effort to get her assessed and treated. We were able to get them an at-home caregiver until we were able as a family to take on that role of support, and other professionals had been extremely helpful in any services they were assigned for. If you're thinking it, you guessed it: my grandpa's son was nowhere in sight. Our family dynamic and system were granting him a second chance to be reliable and consistent in his dad's life, whether that would be taking him to his appointments or spending quality time with him during the day. He was willing to take on this responsibility in complete confidence, but this turned out to bring more conflict into our lives. He didn't show up on the days our family wanted him to, and his communication with us was almost nonexistent. I can remember visiting my grandparents on weekends that I wasn't in school for or had  day off from work, and they would tell me that others might stop by (meaning that my grandpa's son was heading to the house soon). This was always exaggerated, and he would call hours saying he wasn't going to make it. So many instances this happened. The moments he did spend time with his dad were more of the outcomes that my grandpa was not being taken care of properly and was being taken advantage of by his son persuading him to give him the home he was currently living in after his passing.

As a reminder, my grandfather has dementia and even though my grandmother owns the home, if her passing was before his, my grandfather would be in possession of the property. Both the financial exploitation and neglect he was experiencing wasn't easy for him to acknowledge. He didn't think his son did not have ill intentions, but there were more complications than that. My mom and her siblings took authority and completed the process of putting the house under all of their names, as well as report his son's wrongdoings that were later processed by law enforcement. He is no longer close or involved in our family dynamic and is seeking treatment and on a payment plan as his punishments. The trauma that my family endured, especially my grandmother, brought new insight on who would be each and everyone's power of attorney in the future. It gave us a wake-up call to triple check that in our last days, we wouldn't be suffering and having chaos as the center of our lives. I still miss their home to this day, and I know that this was something they never expected to happen.

Resources:

Adult Protective Services (APS) Offices

Kern County: Aging and Adult Services
5357 Truxtun Ave. (just east of Mohawk)
Bakersfield, CA 93309
ATTN: Adult Protective Services / Phone Number: (661) 868-1006

Kings and Tulare County: Area Agency of Aging

Kings Location: 1440 W. Lacey Blvd.

Hanford, CA 93230 / Phone Number: (559) 852-4000

Tulare Location: 3500 W Mineral King Ave.

Visalia, CA 93291 / Phone Number: (559) 623-0651

Center of Medicare and Medicaid Services (CMS):

Phone Number: 1-800-MEDICARE

Special Focus Facility List:

Facility Locator: Find Healthcare Providers: Compare Care Near You | Medicare

SFF Candidates: Nursing Home Special Focus Facility (SFF) List - StarPRO (getstarpro.com)

Lichtenberg Older Adult Nest Egg (Assistance with Financial Exploitation of Older Adults):

Protect older adults from financial exploitation - Older Adult Nest Egg

Supporting Documents:

• Psychology of Aging with Dr. Regina Koepp: Elder Abuse and Elder Abuse Reporting Resources on Apple Podcasts
• https://www.acsh.org/news/2015/12/28/elder-abuse-a-serious-and-underreported-concern
• https://www.npr.org/sections/health-shots/2019/06/12/731820729/reports-find-health-workers-still-arent-alerting-police-regarding-likely-elder-a
• Redmond, Mark A. “Representing Elder Physical Abuse Victims.” GPSolo, vol. 32, no. 6, 2015, pp. 14–17. JSTOR, http://www.jstor.org/stable/24634383. Accessed 31 May 2023.
• Blancato, Robert B., and Meredith Whitmire. “Elder Justice Policy: Where We Are Now and Where Do We Go Next?” Generations: Journal of the American Society on Aging, vol. 44, no. 1, 2020, pp. 106–10. JSTOR, https://www.jstor.org/stable/26992878. Accessed 31 May 2023.