PREVENTING ELDER ABUSE AND NEGLECT
PREVENTING ELDER ABUSE AND NEGLECT
On the completion of Chapter 8, the reader will be able to
• Describe the various definitions and types of elder abuse
• Understand and recognize the signs and symptoms of elder abuse
• Identify the major risk factors of elder abuse
• Become familiar with the identification and reporting requirements related to elder abuse
• Learn about preventing elder abuse in long-term care (LTC) facilities
• Hear about specific case studies that reinforce the concepts of the
• chapter relative to financial elder abuse
According to the World Health Organization (2011),
Maltreatment of elderly people is an important public health problem. While there is little information regarding the extent of maltreatment in elderly populations, especially in developing countries, it is estimated that 4–6% of elderly people in high-income countries have experienced some form of maltreatment at home. However, older people are often afraid to report cases of maltreatment to family, friends, or to the authorities.
Although it is predicted that aging baby boomers will experience health, vitality, and longevity unknown to previous generations of elders, it is also forecasted that many will live with greater levels of disability, frailty, and sadly, vulnerability to abuse. For many years, advocates in the field of elder abuse prevention have pointed out that public awareness about elder abuse has lagged behind other types of family and interpersonal violence such as child abuse and domestic violence. Ageism (Butler, 1969, p. 243) “reflects a deep seated uneasiness on the part of the young and middle-aged—a personal revulsion to and distaste for growing old, disease, and disability; and fear of powerlessness, ‘uselessness’ and death.” Ageism is frequently cited as one of many potential reasons for the relative lack of recognition of elder abuse.
There are hopeful signs that interest in identifying and treating elder abuse and its traumatic aftermath is increasing among health care practitioners, clinicians, researchers, law enforcement, and policy makers. The purpose of this chapter is to provide an overview of the nature and effects of abuse in later life. This is accomplished through the dissemination of relevant information on elder abuse.
OVERVIEW OF ELDER ABUSE
Federal definitions of elder abuse first appeared in the Amendments to the Older Americans Act (OAA). Because each state defines elder abuse according to its unique statutes and regulations, definitions do vary from state to state. Researchers also use varying definitions to describe and study the problem. Domestic elder abuse usually refers to any of the following types of mistreatment that are committed by someone with whom the elder has a special relationship (e.g., a spouse, sibling, or caregiver). Institutional abuse commonly refers to any of the following types of mistreatment occurring in residential facilities (such as a nursing home, assisted living facility, etc.) and is usually perpetrated by someone with a legal or contractual obligation to provide some element of care or protection.
Types of Elder Abuse
Elder abuse can affect people of all ethnic backgrounds and social status and can affect both men and women. Table 8.1 illustrates types of abuse that are commonly accepted as the major categories of elder abuse, including descriptions and examples.
Although there are distinct types of abuse defined, it is not uncommon for an older adult to experience more than one type of mistreatment at the same or different times. For example, an elder who is not going to the doctor or taking appropriate medications may be having those medications stolen and be prevented from seeking care.
Recognizing Signs of Elder Abuse
Possible Physical Abuse Indicators
The following are clues for recognizing signs of physical elder abuse (California Advocates for Nursing Home Reform [CANHR], 2013). It is not intended to be exhaustive:
• Unexplained weight loss, malnutrition, and/or dehydration
• Physical injury: Areas painful on touching, fractures or broken bones
TABLE 8.1 Types of Elder Abuse
|Physical abuse||Use of physical force against an older adult that may result in bodily injury, physical pain, or impairment.||Striking (with or without an object), hitting, beating, pushing, punching, shoving, shaking, slapping, kicking, pinching, burning, inappropriate use of drugs and/ or physical restraints, force-feeding, and physical punishment of any kind.|
|Sexual abuse||Nonconsensual, sexual contact of any kind with an older adult. Sexual contact with any person incapable of giving consent also is considered sexual abuse.||Unwanted touching and all types of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photographing.|
|Psychological abuse||Infliction of anguish, pain, or distress on an older adult through verbal or nonverbal acts.||Verbal assaults, insults, threats, intimidation, and humiliation; treating an older person like an infant; isolating an older adult from his or her family, friends, or regular activities; giving an older person the “silent treatment”; and enforced social isolation.|
|Financial exploitation||Illegal or improper use of an older adult’s funds, property, or assets.||Cashing an older adult’s checks without authorization or permission; forging an older person’s signature; misusing or stealing an older person’s money or possessions; coercing or deceiving an older person into signing any document (e.g., contracts or will); and the improper use of conservatorship, guardianship, or power of attorney.|
|Neglect||Refusal or failure to fulfill any part of a person’s obligation or duties to an older adult. May also include failure of a person who has fiduciary responsibilities to provide care for an elder (e.g., pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care.||Refusing or failing to provide an older adult with such necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials.|
|Abandonment||Desertion of an older adult by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.||Desertion at a hospital, nursing facility, or shopping center with no identifying information.|
Source: National Center on Elder Abuse (2011).
• Bruises and skin damage:
– Bruises on the inner arm or thigh
– Bruises with shape similar to an object or thumb/fingerprints (oval markings from fingers)
– The presence of old and new bruises in the same place as from repeated injury or injuries in different stages of healing
– Clustered marks as from repeated striking; bilaterally on soft parts of body, not over bony parts (knee and elbows)
– Scratches, cuts, pinch marks, choke marks, burns, welts, gag marks, sprains, punctures, bedsores, or fractures
The following are possible behavioral indicators for recognizing signs of elder abuse (CANHR, 2013).
• Hesitation to talk openly
• Implausible stories
• Confusion or disorientation
Possible Relationship Abuse Indicators
The following are clues for recognizing signs of relationship elder abuse (CANHR, 2013).
• The elder may not be given the opportunity to speak for himself or herself
• Obvious absence of assistance, attitudes of indifference, or anger toward the elder by family member or caregiver
• Social isolation or restriction of activity of the elder
• Conflicting accounts of incidents by the family or caregivers
• Substance abuse by individual responsible for the care of the elder
Major Risk Factors
Elder abuse is extremely complex. Generally a combination of psychological, social, and economic factors, along with the mental and physical conditions of the victim and the perpetrator, contribute to the occurrence of elder maltreatment. Although the factors listed below cannot explain all types of elder maltreatment, the following are some of the risk factors researchers think are related to elder abuse.
According to the National Incidence Study on Elder Abuse (National Center on Elder Abuse [NCEA], 1998), the oldest elders (those older than 80 years of age), who made up about 19% of the U.S. older adult population at the time of the study, were far more likely to be the victims of all categories of abuse, with the exception of abandonment (NCEA, 1998). They accounted for over half the reports of neglect (51.8%), and 48.0% of financial/material abuse, 43.7% of physical abuse, and 41.3% of emotional/psychological abuse. In all types of abuse and neglect, older adult victims in the 60 to 64 and 65 to 69 age groups accounted for the smallest percentages. Thus, age is one of the strongest predictors of vulnerability to abuse.
The NCEA found that female elders were more likely to be the victims of all categories of abuse, except for abandonment (NCEA, 1998). Although making up about 58% of the total national older adult population in 1996, women were the victims in 76.3% of emotional/psychological abuse, 71.4% of physical abuse, 63% of financial/material exploitation, and 60% of neglect, which was the most frequent type of maltreatment. A majority of the victims of abandonment were men (62.2%).
Health and Functional Impairment
The term functional impairment refers to any reduction in the person’s ability to perform essential activities of everyday life. A person’s functional abilities usually are assessed according to his or her ability to perform activities of daily living (ADLs) such as dressing, bathing, feeding, ambulating, and toileting, as well as higher level instrumental activities of daily living (IADLs) such as cooking, shopping, bill paying, and using the telephone. These activities are necessary to maintain health independence and quality in an older adult’s life (University of Nebraska Medical Center [UNMC], 2011). The National Incidence Study has found that elders who are unable to care for themselves are more likely to suffer from abuse (NCEA, 1998). Approximately one half (47.9%) of the substantiated incidents of elder abuse involved older adults who are not able to care for themselves, 28.7% who are minimally capable, and 22.9% who are able to care for themselves.
Persons with cognitive impairment are at risk of abuse because they may be unaware of the abuse or unable to defend themselves (U.S. Government Accountability Office [GAO], 2011). There are many reasons that an older person may have cognitive impairment, including potentially reversible conditions such as delirium or adverse reactions to medication, and nonreversible conditions such as a progressive dementia. The term “dementia” describes a progressive, degenerative decline in cognitive function that gradually destroys memory as well as the ability to learn, reason, make judgments, communicate, and carry out daily activities. Although it often includes memory loss, memory loss by itself does not mean that a person has dementia. There are many different causes of dementia, but the most common cause in persons 65 and older is Alzheimer’s disease, which accounts for 47% of all dementias (University of California San Francisco [UCSF], 2010). In the National Incidence Study (NCEA, 1998), approximately 6 out of 10 substantiated elder abuse victims have experienced some degree of confusion (31.6% have been very confused or disoriented and 27.9% have been confused periodically). More recent research has indicated that people with dementia are at greater risk of elder abuse than those without (Cooney, Howard, & Lawlor, 2006). Approximately, 5.4 million Americans older than 65 years have Alzheimer’s-type dementia and, of those, 66% or 3.4 million are women. One of eight Americans has Alzheimer’s disease, and close to half of all of those older than 85 years, the fastest growing segment of the U.S. population, has Alzheimer’s disease (Alzheimer’s Association, 2011). A recent study by Wiglesworth et al. (2010) has found that 47% of participants with dementia had been mistreated by their caregivers.
Mental Health Conditions
According to the NCEA (1998), about 44% of all substantiated abused elders were gauged to be depressed at some level, with about 6% of them severely depressed. One study (Dyer, Pavlik, Murphy, & Hyman, 2000) found that victims of elder abuse who had been referred to a Houston-area hospital had higher levels of depression than older patients referred for other reasons (as cited in GAO, 2011). Another study of older adults in Pennsylvania (Beach, Schulz, Castle, & Rosen, 2010) found that risk of clinical depression was a consistent predictor of financial and psychological abuse. Low self-esteem and substance abuse also were cited as possible risk factors. The loss of a spouse or other family member has been viewed as a factor that may increase elders’ need for care and may result in neglect if there is not an adequate response (Nerenberg, 2008).
Social Support, Resources, and Living Conditions
Social support is a key factor in the prevention of, and recovery from, elder abuse (Nerenberg, 2008). Research suggests that those who lack ongoing and caring connections are at greater risk of abuse. A recent study by Acierno et al. (2010) has indicated that low social support among those over the age of 60 is a predictor of most forms of abuse and that high social support can help prevent abuse. The study has suggested that addressing low social support might have significant public health implications. Those with fewer financial resources may be more dependent on others for their care, have fewer options, and be at higher risk for abuse and neglect. Residents of nursing homes are at high risk for abuse due to frailty and greater cognitive and physical impairments.
Effects of Abuse
Research has indicated that elder abuse affects victims’ health and longevity. For example, one study (Fisher & Reagan, 2006) found that older women in the Midwest who were psychologically abused once, repeatedly, or in conjunction with other forms of abuse, also reported higher rates of bone or joint problems, digestive problems, depression or anxiety, chronic pain, and high blood pressure or heart problems than older women who had not been abused. A 2010 study by Mouton, Rodabough, Rovi, Brzyski, and Katerndahl found a relationship between exposure to abuse and poorer psychological health. They also found that exposure to verbal abuse, even without physical abuse, had a strong effect on psychological health. In a qualitative study of 64 women aged 50 and older who were interviewed about their experiences of violence and abuse, several of the respondents spoke of ongoing health and mental health problems (Hightower, Smith, & Hightower, 2006). A longitudinal study (Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998) comparing abused and nonabused community-dwelling older adults in Connecticut, found that only 9% of those abused at some point between 1982 and 1992 were still alive in 1995, compared to 40% of those who had not been investigated for abuse during that same period.
Although underreported, the annual financial loss by victims of financial elder abuse is estimated to be at least $2.6 billion (MetLife Mature Market Institute, 2009). Unlike younger victims of financial crimes, older victims may not have the ability to recoup losses over time and restitution, if any is forthcoming, may not arrive before the elder victim has died (MetLife Mature Market Institute, 2009). Loss of finances can result in restricted choices with regard to care and services and may result in loss of independence. Deem (as cited in MetLife Mature Market Institute, 2009) indicates that financial losses can result in shame, guilt, or general mistrust, escalating into paranoia or depression.
IDENTIFICATION AND REPORTING
Elder abuse often is called a hidden crime. Victims may be reluctant to report because of shame, particularly as family members are overwhelmingly the perpetrators. Victims may also be unable to report abuse because they are isolated or cognitively and/or functionally impaired (NCEA, 2011). Due to these barriers, it is important that any person who suspects that an elder is being abused or neglected attempts to get help by contacting someone who can respond to the alleged abuse (e.g., physician, Adult Protective Services [APS], law enforcement). Many states have laws that designate mandated reporters of elder abuse. There is wide variability across the United States as to who is a mandated reporter, with some states requiring everyone to report suspected abuse and other states specifying some combination of physicians, home health care providers, mental health service providers, law enforcement officers, and financial institutions (GAO, 2011).
The Role of APS
According to the National Adult Protective Services Association (NAPSA, 2004), APS are those services provided to older people and people with disabilities who are in danger of being mistreated or neglected, are unable to protect themselves, and have no one to assist them. The guiding value of APS is that every intervention should balance the duty to protect vulnerable adults and their right to self-determination.
Interventions provided by APS include, but are not limited to, the following: receiving reports of adult abuse, exploitation, or neglect; investigating these reports; and case planning, monitoring, and evaluation. In addition to casework services, APS may provide or arrange for the provision of medical, social, economic, legal, housing, law enforcement, or other protective, emergency, or supportive services (NAPSA, 2004). Eligibility criteria for receiving APS services are determined by state law and therefore vary from state to state. Eligibility criteria may individually, or in some combination, include age of the victim, type of alleged elder abuse, victim’s vulnerability or dependence, and the victim’s relationship with the perpetrator. For example, in California, an individual must be either 65 or older, whereas in Florida, an individual must be at least 60 and unable to care for or protect himself or herself; and the alleged perpetrator must be a caregiver, family member, or household member (GAO, 2011). One of the aspects that make APS work complex is that adults have the right to refuse services and are presumed to have decision-making capacity unless adjudicated otherwise in court (NAPSA, 2004).
The Role of the LTC Ombudsman
Under the federal OAA, every state is required to have an Ombudsman Program that addresses complaints and advocates for improvements in the LTC system. The Ombudsman Program is administered by the Administration on Aging (AoA). According to the National Long-Term Care Ombudsman Resource Center (NORC, n.d.), the network has 8,700 volunteers certified to handle complaints and at least 1,300 paid staff. The Long-Term Care Ombudsman advocates for residents of nursing homes, board-and-care homes, and assisted living facilities. Ombudsmen provide information about how to find a facility and what to do to get quality care. They are trained to resolve problems, but the consent of a resident is required to share concerns beyond the confidential resident–ombudsman relationship. The types of complaints that Ombudsmen handle include violation of residents’ rights or dignity; physical, verbal, or mental abuse; deprivation of services necessary to maintain residents’ physical and mental health, or unreasonable confinement; poor quality of care, including inadequate personal hygiene and slow response to requests for assistance; improper transfer or discharge of a patient; inappropriate use of chemical or physical restraints; or, any resident concern about quality of care or quality of life (NORC, n.d.).
BEST PRACTICE: PREVENTING ELDER ABUSE IN LTC
The CANHR (2013) offers the following best practices to assist in improving the quality of care and life for older adults living in LTC facilities (i.e., skilled nursing facilities [SNFs], residential care communities, assisted living). This information was produced through a donation from Roberta Dangcil in honor and memory of her mother, Melba L. McCord.
Support Loved One’s Transition to the Care Facility
The decision to consider placement in an LTC facility, such as a residential care facility for older adults (sometimes called assisted living) or a nursing home, is a complex and emotionally demanding process. Preplanning and the involvement of the person entering a care facility will help ease the transition. Unfortunately, there is limited or no planning for many placement decisions. A decision for out-of-home placement is often made in response to a crisis such as a broken hip, heart attack, or stroke.
Even in the best of circumstances, there will be strong feelings of loss and abandonment by the person being placed and guilt by the person assuming responsibility for the placement. Acknowledging these feelings is one way to cope with the transition.
Visiting frequently can also be helpful. During some of these visits, if possible, try to meet other residents, talk to staff, and explore other parts of the facility in an effort to familiarize yourself and your loved one to his or her new environment.
There are some other very practical things that can be done during the transition:
• Make sure that he or she is given a comprehensive assessment. If he or she is being discharged from the hospital, make sure he or she is checked for skin breakdown and possible overmedication.
• Become involved in the care-planning process right away. You know your loved one the best. Assist the facility in getting to know him or her and work with the staff in developing a transitional care plan and then a more comprehensive one.
• Monitor the elder’s needs, changes, and care during the transition. He or she might experience depression, which will affect appetite, sleeping patterns, motivation, and ability to socialize and to participate in therapy or activities. A new environment, a roommate, or different medications can also affect a person. Be attentive to changes and communicate them to the appropriate staff.
Make Your Visits Count
There is more to making your visits count than visiting frequently. Visit at different times and shifts, and on different days of the week. It is also important to visit at meal times, when activities are planned, and definitely at night and on the weekends. These strategies are important to get a full picture of the patterns of care in the facility and the performance and attitude of care staff at different shifts. The unpredictability of your visits can also keep the facility on its toes.
Visits can easily become routine or something that is done out of duty or even dreaded. In addition to the tips above, make a plan for weekly visits. This can bring new purpose, freshness, and sometimes adventure to the visits. In making a plan, here are some considerations:
• What days and times will I visit this week? What do I want to discover this week?
• Who are the residents or staff to meet during this week?
• What section(s) of the facility are we going to visit?
• What can I plan to talk about or do? Is there something that I can bring to talk about or do together? Is there someone I can bring along for a visit?
• Anticipate special occasions and plan something special, for example, birthdays, anniversaries, and so forth.
• Plan occasional outings, if possible.
• Coordinate visits and contacts from family, friends, and volunteers.
Get to Know the Staff and Build Relationships
As part of your plan for visiting, you want to get to know all key staff on a first-name basis on all shifts that care for your loved one. One of the hardest things can be turning over the direct, caregiving responsibilities to someone else, especially if you have been doing it at home for a number of years. Your new role is to provide emotional support to your loved one, to help the staff know your loved one on a personal basis, and to be an advocate.
Generally, staff resent being told how to do their jobs but appreciate knowing more about what your loved one’s likes and dislikes are and what might have worked for you. Genuine praise can go a long way in building good relationships. When you observe a staff member providing good care or handling a difficult situation well, tell the person that you appreciate the quality service. And let the supervisors know about good staff performance.
Develop good working relationships with key administrative and supervisory staff. The director of nursing and charge nurses for the wing will be particularly valuable resources in understanding, questioning, and promoting quality care in skilled nursing homes. The administrator or supervisors in residential care facilities or assisted living facilities are also key persons.
Know the facility’s policy and procedures on who you should go to with concerns or problems. Bring your concerns forward as matters come up that need to be resolved. Do not wait until you have a lot of problems or major issues. Communicate frequently and openly. Again, offer positive feedback when concerns have been addressed or when positive things are happening in the facility.
Be an Active Participant in All Care Plan Meetings
The plan of care describes the strategies that the facility and staff will use to enhance, restore, or maintain a person’s optimal physical, mental, and psychosocial well-being. Care plans are based on assessments and need to be completed before or shortly after a person is admitted as a resident in an LTC facility. Care plans are reviewed and updated whenever there are significant changes in a resident’s physical, medical, mental, behavioral, and/or social conditions. Skilled nursing homes have a quarterly review cycle, whereas residential care facilities for older adults are required to review and update the care plan only annually or when there is a significant change in the resident’s care needs.
The care plan meeting provides an opportunity to evaluate whether the plan is working and to make necessary changes to better meet the individualized needs of the resident. Some tips to make the care plan work for your loved one are:
• Personalize the needs and interests of your loved one.
• Make sure that all key players will attend the care planning meeting, including direct-care staff.
• Bring concerns and suggestions.
• Insist on concrete, measurable plans and a timetable.
• Follow-up the meeting with a written understanding of what is going to be done, by whom, and when.
Use the care plan to monitor the overall care of your loved one. Hold the facility accountable for carrying out the plan in good faith. As indicated above, an effective care plan will be concrete, with many areas to observe and monitor. It will give you many practical things to look for in the overall care and in specific care approaches for your loved one.
In monitoring care, consider using the following approaches depending on the circumstances:
• Keep notes. Write down important facts by answering who, what, when, where, and how questions. Describe what happened. Be as specific as possible. Use quotes if a person made an important statement.
• Check records. With the resident’s permission, or if you are the legal representative or health care agent, you have the right to access and to obtain copies of the medical records, care plan, nursing, and certified nurses aides progress notes and resident’s file. Records can be important sources to see whether the care that is planned for is actually being provided. Make sure that the records are an accurate reflection of what is actually happening and that the records are not being obviously changed or falsified.
• Obtain copies of relevant files whenever there is poor, neglectful, or abusive care.
• Maintain close contact with the doctor. Get a second opinion or obtain assistance to interpret medical or resident records. Check on the medications that have been prescribed and monitor your loved one’s reactions.
• Make a physical inspection of your loved one. A nonintrusive way to do this is to give a back rub to your family member. It is nice for the family member and a good opportunity to inspect for signs of redness or sores. If necessary, take pictures and make complaints to the Ombudsman Program and to the appropriate licensing agency.
Act as an Advocate for Loved Ones
At the heart of effective advocacy is knowledge of the rights of residents and your rights as the representative of the resident. These basic rights should be explained at the time of admission and should be posted in the facility. One of the most important rights is the right to express concerns, suggestions, or to make complaints and to do so without fear of retaliation.
In exercising these rights, strive to maintain a calm manner, act with assertiveness, be persistent, ask for honest communication, and insist on accountability.
Listed below are some additional tips to make your advocacy more effective:
• Follow-up on all concerns identified in monitoring care.
• Ask for meetings with key people to resolve problems. Plan carefully for the meeting by clearly identifying the results that you want. It is important to summarize your understanding of the agreed outcomes, persons responsible, and timetables before the meeting ends. Whenever possible, put this summary in writing and ask that it become part of the resident’s file.
• Contact the Ombudsman Program to assist you in exercising your rights. The ombudsman is the resident’s advocate. A poster with the telephone number for the local Ombudsman Program must be prominently displayed in residential care facilities for older adults and in SNFs.
• File complaints with the appropriate licensing agency. You have the right to confidentiality in making complaints to both the Ombudsman Program and the licensing agencies.
In July 2001, the Congressional Special Investigations Division found that 35% of nursing homes in the United States were cited for more than 10,000 instances of abuse over a 2-year period. The truth is that the percentage is probably higher because abuse often goes unreported.
To prevent abuse, remain active in the care of your loved one by following the tips already presented for visiting, building relationships with staff, actively participating in the care planning process, monitoring care, and acting as an effective advocate. It is also critical to learn signs of elder or dependent-adult abuse and know how to report suspected abuse promptly.
• Some of the signs of physical abuse in care facilities are unexplained bruises, scratches, or marks on face, inner arm, or thigh, or on breast or genital areas. Check for marks caused by use of restraints, for example, belts. Look for signs of overmedication like drowsiness, dry and cracked lips, drooling, and vacant stares.
• Indicators of neglectful behavior are poor personal hygiene, urine smell, residents being left unattended for long periods in bed or on the toilet, unexplained weight loss, malnutrition or dehydration, frequent falling, and signs of skin breakdown and bedsores.
• Financial abuse can occur with lost or stolen personal belongings. There can also be fraudulent billing practices.
• If you suspect abuse, do not wait and try to resolve this alone. Seek help. Contact the Ombudsman Program, make a complaint to licensing, refer any physical or sexual abuse to local law enforcement, and seek the advice of an attorney through CANHR’s lawyer referral service.
Become Active in Quality-of-Care Issues
You are not alone. There are hundreds of thousands of people in nursing homes and residential care facilities in California and throughout the United States. They share many of your concerns. Do not act alone. Support and power can be gained by acting collectively. Group action can offer protection from the fears of retaliation and produce change that can positively affect the quality of care and life for all residents.
• Encourage your loved one to become an active member of a resident council. A nursing home is required to have a resident council and residential care facilities must support the development of a resident council if initiated by residents.
• Family members and concerned friends can either join or form a family council. You can obtain helpful organizing materials, including a video, from CANHR.
• Contact your state and federal elected officials about your concerns of poor care and the need for increased funding for community-based alternatives.
• Support legislation that will enhance resident rights and improve quality of care.
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