Mandated Reporter Training for Suspected Adult Abuse and Neglect

Unit 2

Text-Only Site

Purpose:

Familiarize yourself with the role of Adult Protective Services.

Understand the definitions and indicators of abuse, neglect and exploitation. In order to talk about what is reportable, you must begin with definitions of an incapacitated or dependent adult.

Incapacitated Adult

Any adult who is impaired by reason of mental illness, mental deficiency, physical illness or disability to the extent that that individual lacks sufficient understanding or capacity to make or communicate responsible decisions concerning that individual’s person, or to the extent the adult can not effectively manage or apply that individual’s estate to necessary ends.
(Title 17-A; Section 555)

Dependent Adult

A dependent adult is one who has a physical or mental condition that substantially impairs the adult’s ability to adequately provide for that adult’s daily needs. This includes a resident of a nursing home or assisted living facility. It also includes a person considered a dependent person under Title 17-A;section 555.

Key Points

Adults are presumed to have capacity to give informed consent unless found not to have capacity to make decisions by a Probate Judge in a guardianship hearing. Guardianship will be discussed later.

Informed consent is a decision made with all the relevant information about the issue, with an understanding of the consequences of a decision, and in the absence of duress.

Adults have the right to make their own decisions regardless of how others view those decisions. For example, a competent brittle diabetic who understands the importance of a diet yet chooses not to follow that diet is using poor judgment.

Due to physical or mental impairment, dependent adults require the assistance of others to meet their daily needs.

Some additional definitions you need to know include:

  • Abuse
  • Sexual Abuse
  • Neglect and
  • Exploitation
  • Abuse

The infliction of injury, unreasonable confinement, intimidation or cruel punishment that causes or is likely to cause physical harm or pain or mental anguish; sexual abuse or sexual exploitation; or the intentional, knowing or reckless deprivation of essential needs. Abuse includes acts and omissions.
(Title 22 3472)

Indicators

Physical Indicators

  • Bruises from hitting, shoving, slapping, pinching, or kicking
  • Bilateral injuries, or injuries on upper arms, face, neck or clustered on other body parts
  • Burns caused by cigarettes or hot objects
  • Friction from ropes, chains, or other physical restraints
  • Injuries caused by biting, cutting, poking, punching, whipping or twisting of limbs
  • Disorientation, stupor or other effects of deliberate overmedication
  • Open wounds, cuts, punctures, and untreated injuries, and injuries in various stages of healing
  • Person's report of being mistreated
  • Abuse or neglect of pets in the home

Behavioral Indicators:

  • Easily frightened or fearful
  • Exhibiting denial
  • Agitated or trembling
  • Hesitant to talk openly
  • Implausible stories
  • Extreme upset when assisted with bathing or other physical care giving
  • Depression or poor self-esteem
  • Eating disturbances
  • Compulsive behavior
  • Sleep disorders
  • Interactions between victim or abusers
  • Inconsistence in how they describe events or accounts for injuries
  • Family does not interact with client
  • Marital or family discord
  • Caregiver lacks knowledge of adult's condition and needed care
  • Doctor or hospital hopping
  • A person's sudden change in behavior

Anne's Story

Anne is a 78-year-old woman with mental retardation, who lived her whole life in the same house. Before her mother’s death, Anne’s brother promised their mother that he would not place Anne in an institution.

For almost 30 years, she never left the house. APS responded to a referral and found her locked in her bedroom.

She was lying naked in a fetal position on the bedroom floor and weighed only 67 pounds. She was being fed a diet of crackers and yogurt. There was a badly soiled mattress on the floor, without sheets or blankets. The bedroom did not have toilet facilities.

Of the 12 words she could speak, the three she said the most were “I hate you.”

Sexual Abuse or Exploitation

Contact or interaction of a sexual nature involving an incapacitated or dependent adult without that adult’s consent. (Title 22 3472)

Indicators

  • Physical Indicators
    • Bruises around the breast or genital area
    • Unexplained veneral diseases or genital infection
    • Unexplained vaginal or anal bleeding
    • Torn, stained, or bloody underclothing
    • Painful urination or sitting
    • Difficulty walking or sitting
    • A person's report of being sexually assaulted or raped.
  • Behavioral Indicators:
    • Demonstrates inappropriate sex-role relationship
    • Exhibits inappropriate, unusual, or aggressive sexual behavior
    • Reveals extreme anxiety, including difficulty eating/sleeping, fearfulness, or compulsive behavior
    • Exhibits agitation or anger
    • Feels confused
    • Symptoms of emotional disorders

Abuse Activity

** In the full-version, this is an activity where you type a response to the statement listed and then go to a screen where you can compare your response to other possible answers. For the purposes of providing valuable information in this text-only version, the statements and possible answers are provided below.**

Statement: List some types of abuse:

Possible answers : Slapping; Withholding Food; Withholding Care

Statement: List some physical indicators of abuse:

Possible answers: Bruises from hitting, shoving, slapping, pinching, or kicking; Bilateral injuries, or injuries on upper arms, face, neck or clustered on other body parts; Burns caused by cigarettes or hot objects; Friction from ropes, chains, or other physical restraints; Injuries caused by biting, cutting, poking, punching, whipping or twisting of limbs; Disorientation, stupor or other effects of deliberate overmedication; Open wounds, cuts, punctures, and untreated injuries, and injuries in various stages of healing; Person's report of being mistreated; Abuses or kills pets

Statement: List some behavioral indicators of abuse:

Possible answers: Easily frightened or fearful; Exhibiting denial; Agitated or trembling; Hesitant to talk openly; Implausible stories; Extreme upset when assisted with bathing or other physical care giving; Depression or poor self-esteem; Eating disturbances; Compulsive behavior; Sleep disorders; Interactions between victim or abusers; Inconsistence in how they describe events or accounts for injuries; Family does not interact with client; Marital or family discord; Caregiver lacks knowledge of adult's condition and needed care; Doctor or hospital hopping; A person's sudden change in behavior

Statement: When might an adult choose to stay in an abuse situation?

Possible answers: The adult may be afraid of further harm;The adult sees the relationship as security; The adult has nowhere else to go.

Neglect

A threat to an adult’s health or welfare by physical or mental injury or impairment; deprivation of essential needs or lack of protection from these. It also includes self-neglect. (Title 22 3472)

Indicators

  • Physical Indicators:
    • Dehydration
    • Neglected bed sores
    • Untreated injuries or medical problems
    • Poor hygiene
    • Hunger, malnutrition
    • Pallor, or sunken eyes or cheeks
    • Lack of clean bedding or clothing
    • Lack of glasses, hearing aid, dentures, prosthetic device
    • Skin disorder or rashes
    • Lack of prescribed medication
    • Person's report of being mistreated
  • Behavioral Indicators:
    • Unresponsiveness or helpless
    • Appears detached
    • Exhibits hopelessness
    • Expresses unrealistic expectations about his/her care

Financial Exploitation

The illegal or improper use of an incapacitated or dependent adult or that adult’s resources for another’s profit or advantage. (Title 22 3472)

Indicators

  • Physical Indicators
    • Unusual volume or type of banking activity, or activity inconsistent with victim's ability.
    • Nonpayment of bills
    • Eviction
    • Care of the person is not consistent with the size of the estate
    • Missing property or belongings
    • Suspicious signatures on checks or other documents
    • Caregiver has no means of support
    • Signing blank checks
    • Purchase of items that do not benefit older person, i.e. boats, sports equipment, or real estate
    • Transfer of ownership of property to a "new friend" or relatives with little prior involvement in the elder person's life
    • The person's report of financial exploitation
  • Behavioral Indicators:
    • Implausible explanations about his/her finances
    • Unaware or doesn't understand financial arrangements
    • Concerned or confused about missing funds from their account
    • Abrupt changes in a will or other financial documents
    • Change in spending habits

Bertha's Story

Bertha is 88-years-old and was financially exploited by her two nieces. After becoming her guardian and conservator, the nieces sold her home, her car, her personal belongings, and everything else important to her.

They divided the proceeds and purchased traveler’s checks with some of the money. Her nieces even continued to steal her monthly pension benefits from out of state, utilizing an ATM.

DHHS became her public guardian and had the two nieces removed as co-guardians and co-conservators. Both nieces were prosecuted; one niece received a six-month jail sentence. Restitution is part of their probation.

Key Points

Indicators of abuse are actual signs of symptoms that suggest that abuse has occurred or is likely to occur. They may be physical or behavioral.

  • Physical indicators include injuries or signs of restraint.
  • Behavioral indicators include the conduct of, or interactions between, the victim and the abuser.
  • It would not fit your mandate.

Adults have the right to make their own decisions unless adjudicated incapacitated by a Probate Judge.

Self-neglect refers to persons who may have lost the ability to care for themselves due to their physical or mental impairment, as opposed to persons who have chosen an unsafe lifestyle.

A threat to an adult's health or welfare by physical or mental injury or impairment; deprivation of essential needs or lack of protection from these.

Common Characteristics of Abusive Caregivers

  • Substance Abuse
  • Ongoing mental illness or emotional problems
  • Lack of caregiver experience
  • Reluctance of caregiver
  • History of abuse - more common in families with established patterns or histories of violent behavior.
  • Dependency - often the caregiver is dependent on the elder for financial support.
  • Very friendly and helpful.
  • Personality traits including:
    • Exhibiting hypercritical and impatient behavior
    • Displaying unsympathetic attitude toward the needs of others
    • Blaming the elderly person for caregiving problems
    • Having an unrealistic view of caregiving and lack the understanding of what the adult needs
    • Loss of self-control
    • Feeling of losing their independence

Behavioral Indicators of Abusive Caregivers

  • Verbal berating, harassment, or intimidation
  • Threats of punishment of depriving of essential needs
  • Isolating a person from friends or other family members
  • Treating the individual like an infant
  • Leaving a person alone for long periods of time
  • Withholding affection to gain compliance
  • Unwillingness to comply with service providers in planning for care
  • Obvious absence of assistance, attitude of indifference or anger toward the victim
  • Giving a person no privacy
  • Denying a person the right to make decisions
  • Demonstrates inappropriate sex-role relationship
  • Inconsistent or implausible explanation of injuries
  • Handles the person roughly or in a manner that is threatening, manipulative, sexually suggestive or insulting
  • Excessive concern about cost of caring for the older person or reluctant about spending money or paying bills.

Suspicious Explanations

  • "The injury was an accident."
  • "The victim fell."
  • "There was no abuse...she bruises easily."
  • "It was a gift."
  • "She owed me the money."
  • "He gave me permissions to have, use, borrow it."
  • "I was going to give it back."
  • "He refuses services."

Indicators Activity

** In the full-version, this is an activity where you read a case and then click a box to show which type(s) of abuse you feel are taking place. For the purposes of providing valuable information in this text-only version, the cases and are provided below. Please read the case and decided which type of abuse is taking place. Feel free to discuss it with your Supervisor. **

Case 1

75 year old Stella Dora lives with her son Ralph and his wife, Mabel, and their two children aged five and seven.

The referent is Wanda the ER Nurse from the local hospital.

Wanda reports Stella was brought in by ambulance after being found on the floor by the mailman. She was unable to get up on her own.

The mailman told Wanda that Mabel was home but passed out on the couch with an empty bottle of vodka under her arm.

Her son was believed to be out hunting for the week.

Which type(s) of abuse do you feel is taking place?

Abuse
Sexual Abuse
Neglect
Exploitation
None of the Above

Case 2

In addition to the information in Case 1 the following conditions are present:

Stella has lost a significant amount of weight since her last ER visit 2 months ago, according to Wanda, the ER Nurse and the referent.

Stella has no regular physician.

She takes no known medications.

Upon admission her personal hygiene was terrible - she was filthy and smelled badly and ER staff had to cut the socks off her feet.

Stella relies on Mabel for personal care.

Which type(s) of abuse do you feel is taking place?

Abuse
Sexual Abuse
Neglect
Exploitation
None of the Above

Case 3

In addition to the information in Case 1 and 2, the following conditions are present:

Records indicate Stella has an income exceeding $2,000 monthly, according to Wanda, the ER Nurse and the referent.

Stella has yellow bruises on her upper arms.

Stella is awake and alert but appears unwilling to talk about what happened to her at home.

When her son's name is mentioned her eyes widen and she looks afraid.

She refuses to let go of her pocketbook.

Which type(s) of abuse do you feel is taking place?

Abuse
Sexual Abuse
Neglect
Exploitation
None of the Above

Case 4

In addition to the information in Case 1, 2, and 3, the following conditions are present:

Wanda, an ER Nurse, knows Stella and says her home is filthy, in great disrepair, and the yard is littered with trash and old junk cars and such.

When Adult Protective Intake called Child Protective Intake, they learned that there is no open case on Ralph and his wife, Mabel and they have never been reported for any concerns regarding abuse or neglect of the children.

There is no phone at her house.

The mailman said it was cold inside the house.

Which type(s) of abuse do you feel is taking place?

Abuse
Sexual Abuse
Neglect
Exploitation
None of the Above

Case Study and Review Activity

** In the full-version, this is an activity where you read a case and then answer questions about it. You are given possible answers to compare your responses to. For the purposes of providing valuable information in this text-only version, the cases, questions, and possible answers are provided below. **

Directions provided in the activity: Read each case. Keep in mind the following keypoints are you
complete this activity:

  • Does the report meet the mandate?
  • What other case(s) came in at the same time that is more serious?
  • Is there enough information?

Case 1: 75 year old Stella Dora lives with her son Ralph and his wife, Mabel, and their two children aged five and seven. The referent is Wanda the ER Nurse from the local hospital. Wanda reports Stella was brought in by ambulance after being found on the floor by the mailman. She was unable to get up on her own. The mailman told Wanda that Mabel was home but passed out on the couch with an empty bottle of vodka under her arm. Her son was believed to be out hunting for the week.

Question: Should the abuse concerns you identified be reported to APS?
Answer: * If you suspect abuse, you should always report it.

Question: What other information would be important to have before making a report?
Answer: The following details may be helpful in an investigation: Are there other people/agencies providing assistance? Who might be helpful to the adult within the community? How might the adult react to intervention? Safety concerns including information about weapons in the home? Directions to the house. Dates of birth and social security number. Are there any relatives? Any information about the alleged abuser/perpetrator.

Question: Should APS open a case based on these abuse concerns??
Answer: This case would probably not be opened.

Case 2: In addition to the information in Case 1 the following conditions are present:
Stella has lost a significant amount of weight since her last ER visit 2 months ago, according to Wanda, the ER Nurse and the referent. Stella has no regular physician. She takes no known medications. Upon admission her personal hygiene was terrible - she was filthy and smelled badly and ER staff had to cut the socks off her feet. Stella relies on Mabel for personal care.

Question: Should the abuse concerns you identified be reported to APS?
Answer: * If you suspect abuse, you should always report it.

Question: What other information would be important to have before making a report?
Answer: The following details may be helpful in an investigation: Are there other people/agencies providing assistance? Who might be helpful to the adult within the community? How might the adult react to intervention? Safety concerns including information about weapons in the home? Directions to the house. Dates of birth and social security number. Are there any relatives? Any information about the alleged abuser/perpetrator.

Question: Should APS open a case based on these abuse concerns??
Answer: This case would probably be opened.

Case 3: In addition to the information in Case 1 and 2, the following conditions are present: Records indicate Stella has an income exceeding $2,000 monthly, according to Wanda, the ER Nurse and the referent. Stella has yellow bruises on her upper arms. Stella is awake and alert but appears unwilling to talk about what happened to her at home. When her son's name is mentioned her eyes widen and she looks afraid. She refuses to let go of her pocketbook.

Question: Should the abuse concerns you identified be reported to APS?
Answer: * If you suspect abuse, you should always report it.

Question: What other information would be important to have before making a report?
Answer: The following details may be helpful in an investigation: Are there other people/agencies providing assistance? Who might be helpful to the adult within the community? How might the adult react to intervention? Safety concerns including information about weapons in the home? Directions to the house. Dates of birth and social security number. Are there any relatives? Any information about the alleged abuser/perpetrator.

Question: Should APS open a case based on these abuse concerns??
Answer: This case would probably be opened.

Case 4: In addition to the information in Case 1,2 and 3 the following conditions are present: Wanda, an ER Nurse, knows Stella and says her home is filthy, in great disrepair, and the yard is littered with trash and old junk cars and such. When Adult Protective Intake called Child Protective Intake, they learned that there is no open case on Ralph and his wife, Mabel and they have never been reported for any concerns regarding abuse or neglect of the children. There is no phone at her house. The mailman said it was cold inside the house.

Question: Should the abuse concerns you identified be reported to APS?
Answer: * If you suspect abuse, you should always report it.

Question: What other information would be important to have before making a report?
Answer: The following details may be helpful in an investigation: Are there other people/agencies providing assistance? Who might be helpful to the adult within the community? How might the adult react to intervention? Safety concerns including information about weapons in the home? Directions to the house. Dates of birth and social security number. Are there any relatives? Any information about the alleged abuser/perpetrator.

Question: Should APS open a case based on these abuse concerns??
Answer: This case would probably not be opened if factors from the other cases were not present.

Return to Text-Only Home

Full-Version Home