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Guest Editorial: Why Don't We Talk About Nursing Homes?

If you’ve been in EMS for any length of time, you’ve experienced it: Just starting your shift, you hear the tones. It’s 0630 on a Tuesday morning. The call is at the same nursing home you go to three times a shift, this time for a 75-year-old male “not acting right.”

You arrive at the government-subsidized facility and are confronted with that unique smell you can never get used to. You navigate your cot through the beds, wheelchairs, and equipment. Once inside the room you find your patient with a strong smell of urine and what’s probably a UTI. As you perform your assessment, you send your partner to hunt down a healthcare worker for a report. 

If you’re lucky enough to find a nurse, she’ll probably tell you she’s just gotten on shift and while doing her rounds noticed the patient wasn’t acting right. She called the doctor’s office, and they told her to call the “transport service.”

Being the professional you are, you ask about history, normal mentation, last seen normal, new meds, etc. But your only reply from staff is that they’re unfamiliar with the patient because they were off for the weekend and this isn’t normally their wing. You’re handed a large pile of unorganized paperwork that’s been photocopied so many times you can’t read it. 

You bring the patient to your ambulance and essentially reverse the signs and symptoms reported by the nursing home staff. You transfer your patient to the ER, clean your ambulance, and return to service. You and your partner make a quick joke about how ridiculous the call was, then never speak of it again.

This call, like so many others, is elderly abuse.

The problem we face in EMS is one I call negligence by attrition. Too often paramedics and EMTs observe elderly abuse in nursing homes but don’t report it. Why? We’re acclimated. I can remember early in my career writing up nursing homes that failed basic necessities—poor bathing, residents lying in dried feces, inaccurate reporting by staff. Fast-forward 10 years, and I find myself not even noticing those things, because I’ve become numb to it. And I’m not alone. 

According to the National Center on Elder Abuse, elder abuse occurs in private settings such as homes as well as institutional settings like nursing homes and other long-term care facilities. In 2014 the number of nursing home residents was approximately 1.4 million, and the number of residents in residential care communities was 835,200.

In 2014, according to National Ombudsman Reporting System data, 7.6% of approximately 188,000 complaints reported to ombudsman programs involved abuse, gross neglect, or exploitation. A 2008 study by the U.S. Government Accountability Office revealed that state surveys understate problems in licensed facilities: 70% of state surveys miss at least one deficiency, and 15% miss actual harm and immediate jeopardy of a nursing home resident. Abuse of older residents by other residents in long-term care facilities is now recognized as a more common problem than physical abuse by staff.

But EMS providers report it, right? Wrong.

A 1995 study of prehospital personnel in Michigan found 78% had seen a suspected case of elder abuse or negligence during their careers, and 68% had seen a case during the past 12 months. However, surveyed personnel reported only 27% of suspected cases to authorities. Reasons for not reporting included uncertainty about whom to report to; unclear definitions; being unaware of mandatory reporting laws; and lack of anonymity. A daunting 95% of respondents said training related to elder abuse was not available through their EMS agency.

How is this happening? How can we fix it?

Though states may differ in their mandates for reporting, their goal is the same. Your agency must understand its local, state, and national laws on elder abuse and how to properly report such offenses. In my state of Illinois, a mandated provider who suspects abuse, neglect, financial exploitation, or self-neglect of an eligible adult is required to report the offense within 24 hours to an agency designated to receive such reports. This includes hospitals as well as calling an adult protective services hotline.

I don’t mean to cast blame on skilled nursing home workers—I mean to cast blame on EMS. As a prehospital provider you’ll be going to nursing homes. You’ll deal with the frustrations. But we must stay diligent in our shared goal of patient care and safety. We must remember that the people who live in these facilities are exactly that—people. 

Educate your coworkers and staff on the signs of elder abuse and how to deal with it. Lives depend on it.

Tim Williamson, BS, NRP, NCEE, is EMS program director at Gateway Technical College in Burlington, Wisc. He has worked in EMS/fire for more than 10 years and specializes in emergency management, disaster response, and EMS education.

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