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Introduction   

Home health care generally involves treating patients for illnesses or personal injuries while allowing the patient to maintain a level of independence. Medical services provided include wound care and monitoring physical conditions and vital signs for service serious illnesses, chronic illnesses, and unstable health conditions (1). Other services provided within the home health care scope include nutritional therapy, physical therapy, speech therapy, occupational therapy, and social services.  

The common role of all health care professionals includes the ability to recognize and report elder abuse and child abuse, however teaching the characteristics and assessment of abuse can be difficult (1). Healthcare professionals in the home health setting have an important role in timely detecting, responding to, and reporting abuse. Abuse is defined as the misuse of someone’s goodwill. Negligence on the other hand means not showing the necessary attention (1). 

Elder abuse, child abuse, and neglect have been identified by separating physical, sociological, or financial acts of omission. The clear definition is intentional actions that cause harm or serious risk of harm to vulnerable patients by a caregiver or person to who they have entrusted their care, or failure by the caregiver to satisfy the basic needs or protect the patient from harm (1). 

Role of the Home Health Nurse 

The role of the home health practitioner is to provide care, assess the patient’s living arrangements, assess for needed services, and determine if they have a caretaker. The identification of elder abuse, child abuse, and neglect is a complex process. It requires collaboration between home care professionals and other disciplines including social services, law enforcement, and legal support (2).  

Identification can be very challenging. Routine visits provide unique opportunities for the nurse or health care professional to evaluate risk factors, interventions, and reporting depending on the availability of resources expenses, and local reporting times (2). 

Studies have shown that the risk of child abuse and neglect recurrence significantly decreased after home health programs were in place. Home visiting programs should be provided for families in which maltreatment has already occurred to prevent the recurrence of abuse and neglect and foster a home environment in which children live safely (3).  

The most important skill of the home health nurse practitioner or provider is their assessment skills. To identify abuse and neglect, they must know what signs they’re looking for with each type of abuse. For the patient who has encountered physical abuse, the nurse may know to look for unexplained bruises and physical injuries, frequent trips to the hospital, poor hygiene, or malnutrition (3).  

Patients may start to develop behavioral issues and become withdrawn, have mood swings, agitated or fearful around the caregiver. There may also be environmental changes such as dirty living conditions or lack of adequate resources such as heating, cooling, water, lights, food, and medications (3). 

Injuries such as bruising, abrasions, and lacerations of the head, face, neck, chest, and abdomen are common in elderly patients and children. Bruising around the eyes and cheeks is particularly specific for elder abuse (2, 4).  

An elderly patient who presents to the ER with an isolated forearm fracture may have fallen or been pushed whereas a child with the same forearm fracture could have fallen but it depends on the type of the fracture; asking more questions to understand what happened is necessary by the nurse (2). 

The patients may show signs of depression, anxiety, crying, or being kept isolated. The patient of emotional abuse may be kept isolated from home healthcare providers who can’t see the patient and will have canceled visits (2). 

Physical abuse may cause acute injuries that lead to a health care visit more commonly than other types of elder abuse/mistreatment or child abuse. Home healthcare providers have a unique opportunity to identify this abuse and initiate interventions (2). 

Elder abuse is common and has serious health consequences but is underrecognized by healthcare providers. An important reason for this is the difficulty distinguishing between elder abuse and unintentional trauma. Physical abuse victims are significantly more likely than unintentional fallers to have bruising and injuries on the maxillofacial area, dental, and neck areas. Abuse victims are less likely to have fractures or lower extremity injuries. Abuse victims are more likely to have difficulty trusting home healthcare providers regardless of whether they are children or the elderly population (2, 4). 

Patients with injuries to the face, neck or upper torso will require more in-depth questioning. For all other patients the nurse needs to pause and listen, victims of elder abuse or child abuse will usually disclose their story but may need some assurance that the person they are speaking to wants to hear what they are saying (2). 

The abuse of adults and children with intellectual and developmental disabilities in care services seems to be common (6, 9). How the health care provider would be able to detect and prevent abuse in the vulnerable population includes better staff training, supervision, and monitoring of services (6). 

Statistics of Abuse/Neglect for Dependent Vulnerable Population 

According to a CDC study, it is estimated that one in ten elderly aged 60+ have experienced some form of elder abuse and neglect. Financial exploitation is the most reported type of abuse, followed by emotional, physical, and sexual abuse. Only one in 14 cases of elder abuse is reported to authorities (4). 

The prevalence of elder abuse/neglect in the U.S. ranges from 4.5 to 61.7%. The prevalence of physical abuse was estimated at 7%, financial abuse at 5%, psychosocial emotional abuse at 17%, and neglect at 26% (5, 9). 

According to research from the Centers for Disease Prevention (CDC) each year approximately one in seven children experience abuse/neglect in the United States (5). In 2020 it was reported that 5% to 10% of older adults were victims of elder abuse.  

Although not easily quantified, abuse is estimated to cost billions annually. It is estimated that the global prevalence of child abuse/neglect at around 127/1,000 for sexual abuse, 226/1,000 for physical abuse, 363/1,000 for emotional abuse, 163/1,000 for physical neglect, and 181/1,000 for emotional neglect (3, 4).  

Types of Abuse and Neglect 

There are many types of abuse and neglect, including physical abuse, emotional abuse, financial abuse, and sexual abuse. 

Physical abuse is the striking, pushing, or hitting of the patient inappropriately using restraints and keeping necessary items like glasses or a cane away from the patient (2). 

Emotional abuse includes verbal abuse, calling patients bad names yelling, using vulgar language, and humiliating the patient (2). 

Financial abuse involves taking the property of the patient, mismanaging the patient’s financial accounts, changing the title or deeds of property belonging to the patient, or having the patient make changes to their wills and estate plans to benefit the caregiver.  

Some signs of financial abuse include: 

• Multiple checks written to the patient’s caregiver 

• changing of financial behavior such as frequent ATM withdrawals only when checks were used in the past 

• large value transactions or many small transactions 

• added names to patient’s account permission 

• estate plan changes 

• defaults on or late payments when money was not previously a concern  

(2, 7) 

Sexual abuse includes sexual assault rape, or inappropriate touching of a patient adult, or child, who does not want to be touched or without the mental capacity to give consent. Victims of sexual abuse may show signs like bleeding, soiled undergarments, recurrent UTIs, fearfulness, or sexually transmitted diseases (2, 7). 

Neglect is an act of omission. From adults to children, their caretakers are not doing something they should be doing. This is a failure to meet minimum requirements for care (2, 10). 

Reporting Guidelines 

All 50 states have elder abuse prevention laws with mandatory reporting and child abuse prevention laws. Healthcare professionals are positioned to identify elder abuse, child abuse, and neglect and are mandated reporters. All clinicians should know their state reporting requirements (5). Healthcare professionals working in home health have a crucial position in observing caregivers and raising concerns about possible child abuse/elder abuse and neglect (5, 10).  

Unfortunately, some barriers exist in health care because healthcare professionals are not adhering to mandatory reporting rules and regulations.  

Some of those barriers include: 

• Poor understanding by the healthcare professional of what constitutes abuse and neglect. 

• Older adults do not understand their rights and therefore do not know they can report abuse. 

• Reluctance to report abuse due to fear of reprisal. 

• Feelings of shame, guilt, and embarrassment by the patient. 

• Perceived negative consequences of reporting by healthcare professionals. 

• Fear of retaliation by the perpetrator. 

• Financial dependence upon the perpetrator by the patient. 

• Lack of trust in the system. 

• Cultural norms 

• Sometimes legal barriers  

(8,10) 

A mandatory reporting policy is a strategy aimed to facilitate the identification of child abuse/elder abuse/ neglect incidences by enhancing reporting of suspected abusers to the state Protective Services (8, 10). Home health caregivers have the best opportunity to observe injuries, and they have the training to assess their nature (10). 

Case Study #1 

John is an 82-year-old man who lives with his son and has just received orders for home health to go see him. Upon arrival, the nurse talks with his son who is very rude to her. He escorts her back to Mr. John’s room while yelling vulgar language for him to get up. Upon entering the room there is a strong urine odor. Mr. John is breathing heavily not wearing his prescribed oxygen that is across the room and there’s a foul odor as she approaches his bed.  

The nurse asked the caregiver if he had been changing his wounds and the son stated, “I don’t do those things”. The nurse performs her assessment and finds Mr. John to have these vital signs. T-103.0; Pulse- 116; Respirations-30.  

The nurse calls the doctor to inform him of the situation and asks for an order to send Mr. John back to the hospital because he looks lethargic, the wounds have a foul odor present, he’s breathing very heavily, and has retained 3+ edema. The son is very adamant that he doesn’t want him to go to the hospital, but he goes to the hospital anyway. 

Case Study #2 

Sarah is a 15-month-old girl who has been sick for the past seven months. Her physician orders home health to help with physical therapy, occupational therapy, speech therapy, and nursing. Sarah only says mixed words and she points to what she wants. She’s constantly dirty and wears a diaper that is soiled every time the nurse comes to visit. Sarah only weighs 15 lbs., and she seems very isolated, she has bruising on her thighs and lower legs, and she also has a purple hue around her eye. 

After talking to her mother, the nurse realizes she is only feeding Sarah twice a day, and its usually finger food which Sarah doesn’t like. The mother states Sarah may drink a bottle of milk and one bottle of water a day but then she puts her in her room and lets her play. Sara oftentimes is left with her boyfriend when her mother goes out. When Sarah looks at her mother’s boyfriend she cries and runs to another room. You notice as the home healthcare nurse that Sara always clings to you and has tears in her eyes when you are about to leave. 

Conclusion

The identification of elder abuse and neglect is a complex phenomenon. It requires collaboration between home healthcare professionals and other disciplines which include social services, law enforcement, and legal support. Identification can be very challenging. Routine screening is advisable, knowing and working effectively with local resources is very important.  

The home visit provides a unique opportunity for the nurse or health care professional to evaluate risk factors. Interventions and reporting depend on the availability of resources, education for the healthcare professional, thorough assessments, and local reporting laws. 

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