Nursing home residents are among the nation's most vulnerable. Many suffer from illness, disabilities, Alzheimer’s or dementia, mobility limitations, and speech or hearing impairments. They are often weak, fragile, and unable to defend themselves. A CNN investigative report has exposed that, rather than protecting these vulnerable seniors, many long term care facilities expose them to sexual assault, abuse, and rape. Worse, the abusers are often protected by the facilities, regulators, and legal systems. Although elder sexual abuse can occur anywhere, it ragically occurs most often in nursing homes.
In the explosive exposé, the first installment of which is entitled "Sick, Dying, and Raped in America's Nursing Homes," CNN reported “this little-discussed issue is more widespread than anyone would imagine. Even more disturbing, in many cases, nursing homes and the government officials who oversee them are doing little -- or nothing -- to stop it.”
More specifically, “more than 16,000 complaints of sexual abuse have been reported since 2000 in long-term care facilities.” This number wholly fails to reflect the true extent of the problem because it includes “only those cases in which state long-term care ombudsmen (who act as advocates for facility residents) were somehow involved in resolving the complaints.” As might be expected, ombudsmen are only rarely involved in such incidents, and as a result, the statistic only serves to illustrate a far greater underlying problem.
Regardless, whatever statistics or surveys one is able to ferret from which to create data, sexual abuse in nursing homes and other long term care institutions is vastly under-reported. According to a report prepared by the National Research Council, “a vast reservoir of undetected and unreported elder mistreatment in nursing homes" exist precisely because the population is vulnerable. "Because nursing home residents as a class are both extremely physically vulnerable and generally unable either to protect themselves or report elder mistreatment they experience, the physical and emotional costs of elder mistreatment in such environments are likely to be very high."
Further frustrating appreciation of the problem is wanton concealment by the industry. CNN found, “the federal government has cited more than 1,000 nursing homes for mishandling or failing to prevent alleged cases of rape, sexual assault and sexual abuse at their facilities during this period...[a]nd nearly 100 of these facilities have been cited multiple times during the same period.” CNN interviewed family members who believed their loved ones were being violated as well as nursing home employees who claim to be forced from their jobs for disclosing sexual abuse suspicions. They also spoke to advocates for the elderly and to industry insiders who agreed that immediate change is needed in regard to how alleged sexual abuse reports are handled.
Shockingly, the federal and state regulatory agencies make identification of even reported cases difficult, because, despite the frequency and extent of the problem:
"Despite the litany of abuses detailed in government reports, there is no comprehensive, national data on how many cases of sexual abuse have been reported in facilities housing the elderly."
State health investigators examine all types of abuse reported at nursing homes and assisted living facilities, whether reported by the facilities or flagged by complaints to the state from witnesses, family members or victims. In the case of nursing homes, state officials typically conduct these investigations, as well as routine inspections, on behalf of the federal Centers for Medicare & Medicaid Services (CMS), which regulates the more than 15,000 facilities that receive government reimbursements that pay for many residents' care. Both state health agencies and the federal government then use the information to rate facilities and issue financial penalties for the worst offenders.
CNN surveyed the health departments and other agencies that oversee long-term care facilities in all 50 states. Of the states that could provide at least some data, the responses varied widely. Wisconsin, for example, reported it didn't have a single substantiated report of abuse in the last five years! Worse than the unbelievable, is that most states were wholly unable to say how frequently abuse investigations involved sexual allegations, often stating that sex abuse allegations are not categorized separately from other forms of abuse.
The federal government doesn't specifically track all sexual allegations either. CMS lumps sexual allegations into a category that includes all kinds of abuse, such as physical or financial. CMS told CNN that it did not segregate sexual abuse because it takes all forms of abuse seriously. It is unclear whether CNN asked CMS why, then, it tracks some incidents, rather than others? When asked by CNN, the agency conducted a specialized search using sex-related keywords, but because not every case was sexual in nature, CNN had to review each case individually to filter out any irrelevant citations.
According to CNN, "the reports show that 226 nursing homes have been cited for failing to protect residents from instances in which sexual abuse was substantiated between 2010 and 2015." Of these cases, "around 60% resulted in fines, which totaled more than $9 million -- though only 16 facilities were permanently cut off from Medicare and Medicaid funding." Because the federal government only regulates nursing homes, CNN's analysis did not include assisted living facilities.
In the installment entitled, "Six Women. Three Nursing Homes. And the Man Accused of Rape and Abuse," CNN followed the trail of a nursing aide who was a serial sexual offender, and despite having demonstrated an obvious and discoverable pattern of sexual abuse and rape, was able to move from one facility to another. With a history of sexual abuse allegations, the aid continued to find employment in the nursing home profession. CNN found that nursing home officials are quick to dismiss a resident’s sexual abuse claims as "hallucinations" or "fantasies." CNN also discovered that state labor laws often protected abusers, and discouraged administrators from properly disciplining serial abusers.
Worse, although most offenders are "loners," who commit their abuse secretly and alone, CNN discovered a frightening number of examples in which abusers conspire to commit sexual abuse of the most vulnerable, spurred in part by a form of dehumanizing "mob mentality:"
For months, a group of male nursing aides at a California facility abused and humiliated five male residents -- taking videos and photos to share with other staff members. One victim, a 56-year-old with cerebral palsy, was paraded around naked. Another, an elderly man with paralysis who struggled to speak was pinched on his nipples and penis and forced to eat feces out of his adult diapers. He was terrified his abusers would kill him. While the aides lost their certifications, an investigation by Disability Rights California found that many of them never faced charges.
Another group of nursing aides, teenagers in Albert Lea, Minnesota, tormented at least 15 male and female residents, many of whom suffered from Alzheimer's. The female aides struck, poked and rubbed the residents and touched their breasts. They inserted their fingers into one resident's rectum. They rubbed the residents' crotches and laughed. One aide pulled down her own pants and sat on a female resident's lap -- humping and groping her. "I was basically appalled by the callous disregard for human decency," a judge later said. Two of the abusers, who were 18 at the time and convicted of disorderly conduct by a caregiver, served 42 days in jail. The other teens were tried in juvenile court and faced no jail time at all. (emphasis added).
The psychological and emotional trauma is too easily ignored when exhibited by the elderly. Sexual assault can cause anxiety, depression, suicidal thoughts, PTSD, memory loss, and when combined with strangulation or use of force, even stroke. Victims may have lost consciousness during the assault, and may have trouble recalling details of the sexual assault. They may also be embarrassed by some of their symptoms, such as urinary or fecal incontinence. These effects are often attributable to other causes or conditions suffered by the elderly. Sadly, CNN found that workers often lacked specific training needed to spot sexual abuse -- keeping reports of abuse from ever reaching authorities.
Certainly, many nursing home employees promptly report abusers to authorities as required by federal law and assist in the investigations. But in numerous examples of abuse uncovered by CNN, the facilities themselves made it possible for violent rapes and sexual assaults to go unchecked, unreported, and poorly or incompetently investigated. Allegations are routinely questioned or dismissed because victims have cognitive conditions such as Alzheimer's. According to CNN, "the reputation and safety of the facility may take priority: There's often a fear that bringing investigators into a cash-strapped facility may expose other issues, threaten a nursing home with closure or open the door to costly lawsuits."
CNN reported on one such case:
When the chef at an assisted living facility, was arrested in Louisiana last year in the alleged rape of a 78-year-old resident, a director at the facility, Julie Henry, was quick to issue an emotional statement to local media -- claiming the company was "shocked and disheartened." But not long after, Henry was arrested, accused of orchestrating an elaborate cover-up of the abuse. According to police, she had tried to prevent an investigation by instructing staff not to report the incident. She asked employees at the assisted living facility, Beau Provence Memory Care, to hand over all evidence to her, which she then allegedly destroyed. The chef, Jerry Kan, was indicted on a first first-degree rape charge and has pleaded not guilty. The case is ongoing and his attorney declined to comment.
CNN reported that at the time of publication, "Henry has not been indicted."
The National Association of Health Care Assistants responded with a pledge to act. They stated its members are “saddened and sickened by the CNN investigative report” and planned to increase training and education within its membership. They said this includes ensuring that nursing assistants know how to identify warning signs of potential abuse and the proper mechanism for reporting it to higher authorities.
AMDA – The Society for Post-Acute and Long-Term Care Medicine, also responded:
AMDA emphatically condemns any type of abuse of post-acute and long-term care (PALTC) residents, and stands by its mission to promote and enhance the development of competent, compassionate, and committed medical practitioners and leaders to provide the highest quality, goal-centered care to patients and residents across all PALTC settings.
Adequate education, training, and leadership is vital to ensuring the safety, comfort, and quality of life of PALTC residents and patients. For 40 years, the Society has worked to:
- Train practitioners to identify and report elder abuse – Society educational programs including the Annual Conference, and the Core Curriculum on Medical Direction in PALTC provide education on residents’ rights, elder mistreatment, and more.
- Train practitioners to provide high-quality care to all patients, and to be aware and able to properly deal with issues made more complicated when treating patients with cognitive impairments. Sexual activity among residents in PALTC settings is a challenging topic for all parties. The Society continues to work on educational and policy initiatives to protect and better care for patients with cognitive impairments.
The Society believes that it is vitally important to provide patient-centered care in all circumstances, to all patients, listening to and investigating all complaints, concerns, and other comments by patients and family members. The Society will continue to train health care practitioners, advocate for them, their patients and family members, and educate the public, to advance its mission: A world in which all PALTC patients and residents receive the highest-quality, compassionate care for optimum health, function, and quality of life.
Legislative solutions are often proposed, but provide a mix of possible solutions. On one hand, the State of Missouri is taking measures to allow hidden cameras within nursing homes to catch offenders. Other legislation, however, is aimed at making it much harder to take legal and punitive action against nursing homes that have a problematic past.
Iowa is considering legislation aimed at limiting the legal liability of nursing homes as well as doctors and facilities in the medical industry, in order to cut health care costs affected by huge lawsuit amounts. Advocates for nursing home abuse victims are strongly opposed to such legislation, but they also often oppose on worker and resident privacy grounds remedial efforts, such as cameras. . Some suggest that without the threat of litigation, nursing home companies are free to operate without accountability, notwithstanding that large lawsuit recoveries don't appear to be effective currently in creating accountability.
We are not the first to lament the poor state of knowledge about elder mistreatment. In 1986, a consensus conference of leading researchers (including two of our panel members) was convened at the University of New Hampshire to point the way toward advancing knowledge. The conclusions and recommendations reached at that conference are strikingly similar to those appearing in this report. (emphasis added).
The best solution to institutional care risks remains avoiding institutional care. "Aging in Place" should be a significant discreet objective of your estate and financial plan.
Clients have heard me say many times that the long term care insurance industry is the canary struggling in the mine pointing to greater complications with the current health care system's reliance upon skilled nursing facilities to reduce more expensive hospitalizations. Long-term-care insurance is designed to shield families from crushing nursing home costs. But, the industry has reeled in recent years as health care policy encourages more, not less, institutional care for the elderly. 
