Editor’s note: This article is part of an ongoing series examining how and why New York’s nursing homes too often fail to keep their residents safe. Read more of City & State's investigative reporting on this issue in Part 1, Part 2, and Part 3.
Mistreatment is “highly prevalent” in New York City’s nursing homes, according to a study published this week in the Annals of Internal Medicine. In just four weeks, researchers found hundreds of cases of resident-on-resident mistreatment, virtually all of which were undocumented by nursing home staff and never reported to regulatory authorities, although researchers noted that many of those incidents were minor enough that they would not have been required to be reported.
The study comes on the heels a series of investigative reports by City & State documenting a rise in neglect and abuse in New York’s nursing homes. The research appears to back up stories of resident-on-resident abuse that were previously relayed to City & State by families of nursing home residents, but until now had gone unreported. The families’ stories included violent dementia patients, unwanted touching, and, in one case, daily death threats from a resident’s menacing roommate. The study, however, largely cataloged less extreme behavior.
During a one-month period, the study found that over 20 percent of nursing home residents suffered mistreatment by fellow residents. The study surveyed over 2,000 residents in 10 facilities (five in New York City and five in its suburbs) between 2009 and 2013. The study included incidents of verbal, physical, sexual and other types of mistreatment, including privacy violations and theft. All the incidents had a “high potential to cause physical or psychological distress.” Verbal abuse was most common, but researchers indicated that the numbers of other kinds of mistreatment were still striking.
“These rates were pretty extraordinary, even the quarter that were physical,” said Dr. Mark Lachs, the lead author of the study. Over 28 percent of the 407 incidents (115) were physical, most often hitting or pushing, and 27 incidents were sexual.
The study found that 16 percent of residents were verbally abused, 5.7 percent were physically mistreated, 1.3 percent were sexually mistreated and 10.5 percent were otherwise mistreated. Because some residents suffered multiple kinds of mistreatment, the portion of all residents who were mistreated was 20.2 percent.
It’s important to note, Lachs said, that these incidents were reported over a relatively brief period. “This isn't a one-year prevalence, this is a one-month prevalence,” Lachs said, indicating that the numbers could be even higher over the course of a year.
An editorial by Dr. XinQi Dong, published alongside the study, called for government action. While more research on the subject of elder abuse was needed, Dong wrote, “we cannot wait" for those findings. Dong insisted that changes are needed “at the community, state and federal levels to promote social justice and advocate for enhanced nursing home infrastructure and staff competency to protect residents.”
New York City Councilwoman Margaret Chin, who is chairwoman of the Committee on Aging, said she was working on reforms.
“This study shows what advocates for seniors know all too well – that the problem of elder abuse is growing along with the needs of an expanding senior population,” Chin said. “We are currently working to draft legislation which would create a Senior Patient Bill of Rights for elder New Yorkers in nursing homes and other senior facilities.”
That one in five nursing home residents may be victims of some level of abuse was remarkable even to longtime nursing home resident advocates.
“I am surprised by the extent to which there is abuse,” said Richard Mollot, a leading nursing home reform advocate with the Long Term Care Community Coalition. While Mollot has long decried mistreatment of elderly New Yorkers in nursing homes for a host of other reasons, he hadn’t expected to see such high rates of abuse between residents.
“The fact that there was 20 percent was really striking,” he said. The mistreatment studied was “just resident-on-resident. It doesn't count the staff-on-resident, or neglect, or poor care – which is what we usually focus on,” he said.
Lachs, the study’s author, who is also a leading elder abuse researcher, believes that nursing home residents are actually most commonly abused or mistreated by their fellow residents. "I strongly suspect it’s a much greater risk to residents … than risk of abuse from staff,” Lachs said. An overemphasis on physical abuse by staff among regulators may have caused overseers to miss the resident-on-resident abuse problem. “I think some of the regulatory focus has been a little bit misplaced,” Lachs said.
Nevertheless, Lachs stressed that this did not in any way downplay the seriousness of staff-on-resident abuse. “Let me be very clear,” he said. “We should have zero tolerance for that. These people should be fired, arrested, and prosecuted. No doubt about it.”
Other findings in the study appeared to confirm previous research on the causes of abuse in nursing homes, notably that an overburdened staff leads to poorer patient care.
The study noted that nursing staff levels had an impact on the likelihood of an incident. Nursing home residents cared for by a nursing aide with more than 10 patients were nearly 10 percent more likely to be involved in an incident than those cared for by aides with smaller patient caseloads.
A particularly unsettling finding in the report was that while researchers documented hundreds of cases of mistreatment and abuse, nursing home staff failed to record a single incident report, and just three incidents were mentioned in residents’ medical charts.
Researchers reasoned that nursing home abuse might be so pervasive that it is simply tuned out by nursing staff. The study suggested that residents’ abusive behaviors “are ubiquitous and thus may be considered merely part of the culture and perhaps ignored, unless they result in severe injury.”
Or, the researchers surmised, it “may reflect in part the reluctance of facility staff to provide documentation that may be used in the state survey process that could result in sanctions.”
To Mollot, this problem is nothing new.
“The nursing homes have a responsibility to keep track and report – and they aren't. They aren't at all.” And while nursing homes bear responsibility for this, Mollot said, the state Health Department is guilty of not providing sufficiently aggressive oversight. “Our state agency takes an extremely passive role in enforcing the law. They give the benefit of the doubt, whenever possible, to the provider and that's why residents are victimized.”
A spokesman for the New York State Department of Health said the agency takes resident abuse very seriously, having referred over 1,100 cases to the state attorney general’s office for potential criminal charges in 2015.
The agency spokesman said people with concerns about nursing home care can file a complaint with the health department through the Centralized Complaint Intake Unit by calling 1-888-201-4563.
The Health Department, he added, is currently reviewing the study.