Dependent Adult Abuse Mandatory Reporter Training in Iowa
Abuse Identification and Reporting
Online Continuing Education Course
MANDATORY IOWA DEPENDENT ADULT ABUSE CE. Fulfills the requirement for RNs, LPNs, ARNPs, and all other Iowa mandatory reporters who regularly examine, attend, counsel, or treat dependent adults. 2-hour course approved by the Iowa Department of Public Health, approval number 3998.
Course Price: $20.00
Contact Hours: 2
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This IA DPH-approved course (approval #3998) fulfills the 2-hour CE requirement for Iowa mandatory reporters, including RNs, LPNs, and ARNPs, who regularly examine, attend, counsel, or treat dependent adults in Iowa.
Dependent Adult Abuse Mandatory Reporter Training in Iowa
Abuse Identification and Reporting
Copyright © 2017 Wild Iris Medical Education, Inc. All Rights Reserved.
LEARNING OUTCOME AND OBJECTIVES: Upon completion of this course, you will have the current, evidence-based information and tools you need to accurately identify and report dependent adult abuse in the state of Iowa. Specific learning objectives include:
- Define dependent adult abuse according to Iowa Code.
- Recognize the physical, psychological, behavioral, and environmental indicators.
- Discuss the causes and risk factors for dependent adult abuse.
- Explain the reporting process and barriers to reporting suspected abuse.
- Describe the assessment protocol utilized by investigating agencies following a receipt of a report.
- Summarize the confidentiality and immunity provisions, penalties for failure to report, and legal accountability for mandatory reporters.
- List recommended prevention interventions for dependent adult abuse.
TABLE OF CONTENTS
Dependent adults are individuals aged 18 years or over who are incapable of acceptable self-care due to physical or psychological conditions and who require assistance from other individuals for care (IA DHS, 2017a; IAC 235B.2). The abuse and mistreatment of individuals with a disability and dependency on others is a hidden epidemic, with a massive number of invisible victims. Elder abuse and elder mistreatment are similar forms of adult abuse.
The abuse of dependent older adults by family members in particular dates back to ancient times. It often remained a private matter, hidden from public view. Mistreatment of the elderly and dependent older adults was first described in modern scientific literature under the term granny battering (Burston, 1975). Today, this sort of abuse is considered a social welfare issue as well as a public health and criminal justice concern.
The sadness that accompanies dependent adult abuse is incomprehensible and overcoming at times. Disabled and older adults are sometimes abused by the very people entrusted to help them, including professional caregivers (e.g., personal assistants, health technicians, home health aides, nursing assistants) and family members. Dependent adult abuse is known to occur anywhere: at home, in healthcare facilities, and within the community at large.
When abuse does occur, the dependent adult’s personal health, safety, and emotional well-being becomes eroded and at risk, along with their ability to engage in daily life activities.
The following timeline describes steps taken in the state of Iowa in recent decades to protect its dependent adults from abuse.
|Source: IA DHS, 2017a.|
|1972–1982||Elder abuse subcommittee of Iowa’s Department of Elder Affairs conducts meetings to protect dependent adults from abuse.|
|1982||The first Iowa law is passed concerning the protection of dependent adults.|
|1988||Mandatory reporting of abuse is established in Iowa.|
|1994||Assault is added to physical abuse; injury is no longer necessary to report.|
|1997||Iowa begins mandatory criminal and abuse background checks on prospective employees of healthcare programs.|
|2001||Two special Iowa Division of Criminal Investigation (DCI) agents are established as liaisons between law enforcement and the Department of Human Services (DHS).|
|2008||Iowa Department of Inspections and Appeals (DIA) establishes the Dependent Adult Abuse Code for licensed facilities and programs.|
Dependent adult abuse is one of the largest underrecognized and underreported problems within the United States. It is estimated that only 1 in 14 incidents of dependent adult abuse will come to the attention of law enforcement or human service agencies. Such abuse is far less reported than child abuse or domestic abuse due to lack of tracking, research, and public awareness (IA DHS, 2017a; NCOA, 2017).
Most states did not establish protective services for adults to address dependent adult abuse until the mid-1980s. To compound the problem, medical and criminal justice communities have lacked comprehensive forensic guidelines for the identification of abuse of dependent older Americans, leading to problems with detection, conflicting definitions of the crime, and underreporting (NCOA, 2017). What data has been collected by independent researchers illustrates a troubling reality:
- Dependent adults who experience abuse had a 300% greater risk of death when compared to those who had not been abused.
- In 60% of dependent adult abuse incidents, the perpetrator was a family member; two thirds of perpetrators are adult children or spouses of the victim.
- Financial abuse and fraud costs for older Americans are estimated at over $36.5 billion annually.
- Roughly 50% of older individuals with dementia are abused or neglected by caregivers annually.
With the aging of America, along with longer life expectancies, more individuals will be living out their lives in care facilities. This expanding facility population has brought issues of the quality of care to the forefront. Data on the extent of dependent adult abuse in institutions, nursing homes, and other care facilities are scarce, however, research and surveys suggest high rates of abuse in such facilities (see box below).
ABUSE IN CARE FACILITIES
- An estimated 50% of care facility staff admit to mistreating (i.e., physical violence, mental abuse, neglect) dependent older adults in America annually; two thirds of these incidents involve neglect.
- Most dependent adult abuse in care facilities leads to preventable harm, including $2.8 billion annual Medicare hospital costs alone (excluding additional—and substantial—Medicaid costs caused by the same incidents).
- Facility residents with cognitive incapacities (i.e., dementia, Alzheimer’s disease) suffer 100% greater economic losses in financial exploitation than those without such incapacities.
- Dependent adult abuse in care facilities triples the risk of premature death.
- Only 20% of abuse cases are estimated to ever get reported (believed due to residents’ cognitive or confidence level to report).
- 44% of care facility residents state they have been abused.
- 95% of care facility residents state they have been neglected or seen another resident neglected.
- 17% of certified nursing assistants (CNAs) report pushing, grabbing, or shoving a care facility resident.
- 23% of CNAs report yelling at a resident.
(NCEA, 2012; Connolly et al., 2014)
Among U.S. Population with Disabilities
Individuals with disabilities are victimized by abuse at much higher rates than the rest of the population and are often targeted specifically because of their disability. As compared to the rest of the population, victims with disabilities experience higher rates of victimization by persons known to them and they report the crime far less frequently—often due to the nature of their disability (i.e., cognitive or physical disabilities or mental illness). This abuse of the older adults in our country, with a disability or not, is eye-opening in that the majority of times it takes place in the older adult’s own home (Baladerian et al., 2013).
In the largest survey of its kind in the United States, the Disability and Abuse Project released a report in 2012–2013 entitled “Abuse of People with Disabilities: Victims and Their Families Speak Out.” The report was a rare look into the experiences of 7,200 survey participants (i.e., family members, advocates, service providers, and various types of professionals) who were asked about abuse and bullying by a personal assistant. The survey respondents represented all 50 states and the District of Columbia.
- Over 70% of people with disabilities reported having been victims of abuse.
- More than 50% of these experienced physical abuse.
- Approximately 41% of these experienced sexual abuse.
- Nearly 90% suffered verbal or emotional abuse.
- Most experienced abuse on more than 20 occasions.
- About 50% of abuse incidents were not reported to authorities.
- When reports were filed, only 10% of alleged perpetrators were arrested.
- Approximately 1/3 of victims received therapy.
- Fewer than 5% received benefits from victim compensation programs.
(Baladerian et al., 2013)
In Iowa, the scope of the problem is reflected to some degree in the number of dependent adult abuse allegations received by the Department of Human Services. (These reports pertain to abuse cases in the community but not to those reported in care facilities.)
|Type of Abuse||Number of Allegations||Percentage Founded|
|Source: IA DHS, 2017b.|
|Denial of care by caretaker (neglect)||482||11.8%|
|Denial of care by adult (self-neglect)||290||20.0%|
DEFINITIONS OF ADULT ABUSE PER IOWA STATE LAW
Adult abuse can be broadly understood as including abuse of dependent adults, vulnerable elders, and disabled adults by those involved in their care. Iowa law addresses these forms of abuse in chapters 235B, 235E, and 235F of the Iowa Code (IAC), which provide definitions relating to such abuse.
Dependent adult means a person 18 years of age or older who is unable to protect one’s own interests or unable to adequately perform or obtain services necessary to meet essential human needs, as a result of a physical or mental condition which requires assistance from another, or as defined by departmental rule (IAC 235B.2).
In the context of facilities and programs, dependent adult means a person 18 years of age or older whose ability to perform the normal activities of daily living or to provide for one’s own care or protection is impaired, either temporarily or permanently (IAC 235E.1).
Vulnerable elder means a person 60 years of age or older who is unable to protect himself or herself from elder abuse as a result of age or a mental or physical condition (IAC 235F.1).
Caretaker means a related or nonrelated person who has the responsibility for the protection, care, or custody of a dependent adult as a result of assuming the responsibility voluntarily, by contract, through employment, or by order of the court (IAC 235B.2).
Caretaker also means a person who is a staff member of a facility or program who provides care, protection, or services to a dependent adult voluntarily, by contract, through employment, or by order of the court (IAC 235E.1).
Iowa has adopted the U.S. Americans with Disabilities Act (ADA) definition for this term. Disability means, with respect to an individual:
- A physical or mental impairment that substantially limits one or more major life activities of such individual
- A record of such impairment, or
- Being regarded as having such an impairment
Major life activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. A major life activity also includes the operation of a major bodily function, etc. (LII, 2008).
The ADA does not extend protection to people with transitory or minor disabilities (i.e., with a duration of less than six months), but the disability can be episodic, as long as it substantially limits life activities when it is active. Likewise, having a disability does not in and of itself meet the criteria for being a dependent adult; many people with disabilities live independently.
Categories of Abuse
Dependent adult and elder abuse include the following categories, all resulting from the willful, negligent acts or omissions, including misconduct, gross negligence, or reckless acts, of a caretaker:
- Physical abuse
- Sexual abuse
- Sexual exploitation
- Physical or financial exploitation
- Neglect (also referred to as deprivation or denial of critical care)
- Self-denial of critical care
(IAC 235B.2, 235E.1, 235F.1)
Physical abuse includes willful or negligent acts or omissions that result in physical injury; injury at variance with the history given of the injury; unreasonable confinement; unreasonable punishment; or assault of the dependent adult (IAC 235B).
Sexual abuse includes the commission of a sexual offense under IAC Chapter 709 or IAC Section 726.2 with or against a dependent adult or vulnerable elder. Such offenses include:
- First-degree sexual abuse
- Second-degree sexual abuse
- Third-degree sexual abuse
- Indecent exposure
- Assault with intent to commit sexual abuse and incest
- Sexual exploitation by a counselor or therapist
- Sexual exploitation by a caretaker
- Invasion of privacy, nudity
Sexual exploitation includes any consensual or nonconsensual sexual conduct with a dependent adult. This includes but is not limited to:
- Touching the clothed or unclothed inner thigh, breast, groin, buttock, anus, pubes, or genitals
- Sex act as defined in IAC Section 702.17
- Transmission, display, or taking of electronic images of the unclothed breast, groin, buttock, anus, pubes, or genitals of a dependent adult by a caretaker for a purpose not related to treatment or diagnosis or as part of an ongoing assessment, evaluation, or investigation
Exploitation of a dependent adult or vulnerable elder includes taking unfair advantage of that individual’s physical or financial resources for one’s own personal or financial profit without the informed consent of the individual, including theft by the use of undue influence, harassment, duress, deception, false representation, or false pretenses.
Exploitation also includes acts by a caretaker to obtain, use, endeavor to obtain to use, or misappropriate a dependent adult’s funds, assets, medications, or property with the intent to temporarily or permanently deprive that individual of the use, benefit, or possession of those funds, assets, medications, or property for the benefit of someone other than the dependent adult (IAC 235E.1).
Neglect, or denial of critical care, includes depriving the dependent adult or vulnerable elder of the minimum of:
- Physical or mental healthcare
- Other care necessary to maintain that individual’s life or health
Self-neglect means situations in which the neglect is the result of the acts or omissions of the dependent adult him- or herself. This may take the form of the individual refusing care or being unable to provide for his or her own care, resulting in a threat to health or safety (IAC 235B).
Personal degradation means a willful act or statement by a caretaker—including the taking, transmission, or display of an electronic image—intended to shame, degrade, humiliate, or otherwise harm the personal dignity of a dependent adult, or where the caretaker knew or reasonably should have known the act or statement would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person (IA DIA, 2017a).
PREVALENCE OF DEPENDENT ADULT ABUSE, BY TYPE
In one study, researchers found that 1 in 10 respondents reported emotional, physical, or sexual mistreatment or potential neglect by a family member in the past year (NCOA, 2017). The one-year prevalence of abuse varied by type (see below), and the most consistent correlates of mistreatment across abuse types were low social support and previous traumatic event exposure.
- Physical abuse, 1.6%
- Sexual abuse, 0.6%
- Psychological abuse, 4.6%
- Financial abuse, 5.2%
- Neglect, 5.1%
Source: Acierno et al., 2010.
Circumstances Not Constituting Abuse
Certain situations encountered by caregivers are defined by Iowa law not to constitute abuse of the dependent adult or vulnerable elder. These include:
- Circumstances in which the individual declines medical treatment if he or she holds a belief or is an adherent of a religion whose tenets and practices call for reliance on spiritual means in place of reliance on medical treatment
- Circumstances in which the individual’s caretaker, acting in accordance with the individual’s stated or implied consent, declines medical treatment or care
- The withholding or withdrawing of healthcare from an individual who is terminally ill in the opinion of a licensed physician, when the withholding or withdrawing of healthcare is done at the request of the dependent adult or at the request of the individual’s next of kin, attorney in fact, or guardian pursuant to the applicable procedures under Iowa law
- Good faith assistance by a family or household member or other person in managing the financial affairs of an individual at the request of the individual or at the request of a family member, guardian, or conservator of the individual
- Touching which is part of a necessary examination, treatment, or care by a caretaker acting within the scope of practice or employment of the caretaker; the exchange of a brief touch or hug between the individual and a caretaker for the purpose of reassurance, comfort, or casual friendship; or touching between spouses or domestic partners in an intimate relationship
(IAC 235B.2, 235E.1, 235F.1)
Ellen is 85 years old and lives with her 50-year-old son, Jack. Since Ellen’s health is deteriorating, she needs assistance with activities of daily living, especially using the toilet and dressing. Jack has agreed to serve as his mother’s caretaker, but he is not consistent with assisting his mother when she indicates she needs help. Therefore, she sometimes remains lying in a urine-soaked bed for hours without clothing or blankets for warmth. Ellen has developed a urinary tract infection as well as pressure ulcers on her back due to Jack not responding to her elimination needs and not repositioning her in the bed.
Finally, Jack takes his mother to the local hospital’s emergency room when she becomes too sick to get out of bed. Ellen is admitted with a high temperature. The attending physician immediately suspects abuse, and she immediately acts to make a report. Investigators determine that Jack’s actions constitute neglect because he has not provided his dependent mother with the minimum care she requires.
Lester is 76 years old and lives in a dilapidated cabin along the river and about five miles from town. He is a chronic alcoholic, spending the majority of his monthly income on alcohol instead of groceries. Lester has type 2 diabetes, and he no longer remembers to take his insulin on time.
Lester’s water and electricity were cut off last week since he had not paid his bills for several months. He now uses only river water for cleansing and eats whatever old, canned foods he can find in the kitchen. Due to his poorly controlled diabetes, he has developed ulcers on his feet that have become infected.
When visiting from out of town, Lester’s adult son Charlie discovers his father’s poor living conditions, deteriorating personal hygiene, and ill health. He also notices that his father has become more mentally confused. Charlie tells his dad that he is worried about his health and safety, but Lester angrily insists that he is free to live his life the way he wants.
When Charlie leaves his father’s cabin, he immediately contacts the local county sheriff’s office for assistance and to make a “welfare check” to evaluate his father’s condition. Law enforcement visits Lester’s home. Suspecting self neglect, they report the case to the Iowa Department of Human Services, which investigates further and assists Lester to address his physical and mental health, hygiene, and safety issues.
RECOGNIZING ADULT AND ELDER ABUSE
Healthcare professionals should be aware of possible indicators of abuse when caring for adults who are dependent, disabled, or elderly. Dependent adult and elder abuse can be recognized by many indicators both among those adults who are victims of such abuse as well as among their abusers. It is important to be aware, however, that signs and symptoms of adult abuse are dependent on the type of abuse and that the indicators described below do not necessarily indicate abuse.
The complexity within and between cases of dependent adult abuse make it difficult to establish assessment criteria to meet profiles of signs and symptoms of victims. There have been a succession of tools—such as the EASI (Elder Abuse Suspicion Index)—introduced and used with some success (Hoover & Polson, 2014). Common recommendations described within the literature for abuse assessment with dependent adults include:
- Separate the dependent adult from the caregiver when carrying out an assessment.
- Pay special attention to the physical and psychological aspects of the assessment.
- Be aware that physically abused older adults are more likely to have significantly larger bruises and will readily identify the cause of that injury.
- Bruises will most likely occur on the face, lateral aspects of the right arm, and the posterior torso (i.e., back, chest, lumbar, and gluteal regions).
- Bruises may be in various stages of healing from frequent falls, fractures, dislocations, burns, and human bite marks.
Possible victim indicators of dependent adult abuse are described below, grouped into the categories of physical, behavioral/psychological, environmental, and financial (NCOA, 2017). This list is not all-inclusive.
POSSIBLE PHYSICAL INDICATORS
- Lack of medical care
- Lack of personal cleanliness and grooming, body odors
- Swollen eyes or ankles
- Decayed teeth or no teeth
- Bites, fleas, sores, lesions, lacerations
- Injuries incompatible with explanation
- Bruises, broken bones, or burns
- Untreated pressure sores
- Signs of confinement (i.e., tied to furniture, locked in a room, etc.)
- Obesity, malnourishment, or dehydration
- Broken glasses (frames or lenses)
- Drunk, overly medicated
- Lying in urine, feces, old food
- Petechiae (small, purplish, hemorrhagic spots on the skin) around the eye orbits from strangling
- Dislocated joints (especially in shoulder from being grabbed)
POSSIBLE BEHAVIORAL AND PSYCHOLOGICAL INDICATORS
- Not dressing appropriately for the weather conditions
- Wearing all of one’s clothing at once
- Living on the street (homeless)
- Intentional physical self-abuse, suicidal statements
- Refusing needed medical attention
- Refusing to take medications
- Not following medication directions
- Threatening or attacking others physically or verbally
- Refusing to open the door to a visitor
- Spending the day in total darkness
- Denying obvious problems (i.e., medical condition, etc.)
- Exhibiting increased depression, anxiety, or hostility
- Being withdrawn, reclusive, suspicious, timid, unresponsive
- Refusing to discuss the situation
- Expressing unjustified pride in self-sufficiency
- Disoriented as to place and time
- Exhibiting diminished mental capacity (i.e., dementia)
- Longing for death with vague health complaints
POSSIBLE ENVIRONMENTAL INDICATORS
- No food in the house or rotten, infested food
- Lack of proper food storage
- Clothes extremely dirty or uncared for
- Utilities cut off or lack of heat in winter
- Lack of water or contaminated water
- Doors or windows made out of cardboard
- Unvented gas heaters, chimney in poor repair
- Gross accumulation of garbage, papers, and clutter
- Large number of pets with no apparent means of care
POSSIBLE FINANCIAL INDICATORS
- Sudden changes in bank account practices
- Unexplained withdrawal of a great sum of money
- Adding names on a bank signature card
- Unapproved withdrawal of funds using an ATM
- Sudden changes in a will or other financial documents
- Unexplained missing funds or valuables
- Unpaid bills despite having enough money
- Forged signature for financial transactions or for the titles of property
- Sudden appearance of previously uninvolved relatives claiming rights to a person’s affairs and possessions
- Unexplained sudden transfer of assets
- No knowledge of own finances
- Caretaker overly interested in finances of the dependent adult
- Isolation of the dependent adult
- Caregiver refusing to allow visitors (socialization) to see the dependent adult alone
- Loss of personal belongings such as art, silverware, jewelry, or other valuables
Possible perpetrator indicators of abuse are described below. This list is not all-inclusive.
- Not allowing the dependent adult to speak for himself/herself or to others without the presence of the caregiver
- Obvious absence of assistance, attitudes of indifference, or anger toward the dependent individual
- Blaming the dependent individual (e.g., accusation that incontinence is a deliberate act)
- Failure to provide physical aids such as eyeglasses, hearing aids, or dentures
- Withholding of food and water
- Failure to help with personal hygiene
- Aggressive behavior such as threats, insults, or other verbal harassment
- Social isolation of the family or restriction of the older adult’s activity in a social unit
- Conflicting accounts of incidents by family, supporters, caregiver, or victim
- Unwillingness or reluctance to comply with service providers in planning for care of the dependent adult
- Unauthorized withdrawal of the dependent adult’s funds using their ATM card or checks
(Amstadter et al., 2011; NCEA, n.d.)
|Sources: ASA, 2016; AoA, 2016.|
|Perpetrator (Care Provider)|
Caregivers may exhibit abusive behaviors with dependent adults and/or participate in neglectful behaviors toward the victim. The following table summarizes the types of dependent adult abuse including examples of abusive actions and warning signs and symptoms of abuse.
|Type of Abuse||Abusive Act||Signs and Symptoms|
|Source: Adapted by permission from Salsbury, 2011.|
|Psychological or Emotional||
|Sexual Abuse or Exploitation||
|Financial or Physical Exploitation||
The dynamics of dependent adult abuse are context dependent. Risk factors for the abused (victims) and the abusers (perpetrators) differ according to the context. Most of the caregiving, and thus abuse, occurs within the family structure (i.e., community context). Common risk factors in the community context are described below.
POSSIBLE VICTIM RISK FACTORS
- Married and white
- Lower socio-educational level
- Female 80 years of age or older
- Lives with abuser but socially isolated
- Aggressive toward self and others
- Mental or physical impairment or disability
- Dependence on abuser
- Resides in unsafe or inadequate housing
- Numerous serious illnesses
- Increasing dependence for financial support
POSSIBLE PERPETRATOR RISK FACTORS
- Mental health or substance abuse issues
- Financial dependence on abused/victim
- Past or current health problems
- History of abusing and being abused
- Stress or frustration with caregiving role
- Feelings of being unduly burdened
- Poor coping mechanisms
- Poor support system
- Criminal background
- Being an adult child, sibling, or spouse of a dependent adult
- Living with a dependent adult
- Social isolation
- Lack of employment
- Male between the ages of 30 and 59 years
DYNAMICS OF ABUSERS
Abusers often act out of a desire to gain and maintain power and control over the victim. Their tactics may include setting the rules for living arrangements, professing to love the older person (i.e., “sweetheart scams”), or intimidating and manipulating victims to gain some type of benefit. The perpetrator’s “entitlement thinking” may lead him or her to believe that his or her wants and needs are greater than the victim’s.
Predatory individuals may seek out dependent older adults with the intention of exploiting them. This may include seeking employment as a personal care attendant or contacting recently widowed persons identified through newspaper death announcements. Recent research has indicated the most frequent underlying behavior of the abuser is entitlement thinking patterns and the desire to exert and maintain power over the victim.
Source: EALL, 2017.
IOWA LAWS REGARDING REPORTING SUSPECTED ABUSE
The dependent adult abuse and elder abuse laws in Iowa provide for evaluations and assessments of alleged abused dependent adults and elders. These laws seek to provide services and make referrals to assist abused adults to acquire a safe living arrangement. Protective Service Units are available in all of Iowa’s DHS county offices (IA DHS, 2017a).
The primary purpose of the Iowa reporting process is to obtain available and pertinent information regarding the allegation of abuse. The ability of the reporter to gather this information is critical to the DHS evaluation and assessment process and is often the first step taken to initiate safeguards for the dependent adult at risk. The intent of the law is to accept and process valid reports while not infringing on an adult’s right to privacy (IA DHS, 2012).
A thorough intake will provide:
- Protection for the dependent adult
- Necessary information for the assigned worker
- Information and referral
- Improved public awareness of the Department’s roles, responsibilities, and limitations
(IA DHS, 2012)
Protection for the dependent adult in Iowa is provided by:
- Encouraging the reporting of suspected cases of abuse
- The prompt and thorough evaluation or assessment of the reports
- Intervening to provide protection to abused dependent adults
- Arranging for services for abused dependent adults
(IA DHS, 2012; IAC 235B & IAC 235E)
All allegations of abuse must be taken seriously whether they come from the patient, family, healthcare professional, neighbor, friend, or other service provider. Concerns must be reported to those responsible for assessment and followed up by inquiries about the nature and circumstances of the allegation.
The Iowa Department of Human Services (DHS) accepts reports of suspected dependent adult abuse that occurs within the community, evaluates those reports, completes an assessment of needed services, makes referrals for services, and maintains a central registry of abuse information (IA DHS, 2012).
The Iowa Department of Inspections and Appeals (DIA) accepts and completes reports of suspected dependent adult abuse that occurs within facilities (IA DHS, 2012).
Who Must Report?
Forty-four states, including Iowa, have laws designating certain professionals as mandatory reporters of dependent adult abuse (Schmeidel et al., 2012).
Mandatory reporters of dependent adult abuse in Iowa include those for whom the nature of their work requires them by law to report suspected abuse. IAC 235B3.2 states:
A person who, in the course of employment, examines, attends, counsels, or treats a dependent adult and reasonably believes the dependent adult has suffered abuse, shall report the suspected dependent adult abuse to the Department [of Human Services]. Persons required to report include all of the following:
- Member of the staff of a community mental health center
- Peace officer
- In-home homemaker-home health aide
- Individual employed as an outreach person
- Health practitioner
- Member of the staff or an employee of a community living service, sheltered workshop, or work activity center
- Social worker
- Certified psychologist
- Care review committee member assigned to an elder group home
IAC 235E.2 also lists staff members and employees of a facility or program as mandatory reporters who must report suspected abuse to the Department of Inspections and Appeals.
Facility means a healthcare facility as defined in IAC 135C.1 or a hospital as defined in IAC 135B.1. Program means an elder group home as defined in IAC 231B.1, an assisted living program certified under IAC 231C.3, or an adult day services program as defined in IAC 232D.1.
All Iowa mandatory reporters must complete a training course (such as this one) approved by the Iowa Department of Public Health within six months of initial employment or self-employment. Licensed professionals within the state of Iowa must complete the training course according to the licensing board with authority over their profession. Generally, this training is required as a condition of the new licensure. From then on, Iowa mandatory reporters must complete two hours of continuing education/training every five years (IBN, 2015; IAC 235B.16).
Any person who believes a dependent adult has suffered some form of abuse may report the suspected abuse to the Department of Human Services or to law enforcement. This is referred to as permissive reporting. For example, an employee of a financial institution may voluntarily report suspected financial exploitation of a dependent adult.
It is important to note that mandatory reporters may also report suspected abuse outside the scope of their professional practice, as permissive reporters.
KEY CONCEPTS FOR NURSE MANDATORY REPORTERS
The registered nurse is contextually involved in the dynamics of dependent adult abuse merely by the professional responsibility as a mandatory reporter and an advocate for patients. Some of the key concepts involved within the profession of nursing include:
- Nurses must maintain updated knowledge of signs and symptoms of suspected dependent adult abuse.
- Nurses must maintain updated knowledge of Iowa law pertaining to dependent adult abuse.
- Nurses have a legal responsibility to report suspected abuse of dependent adults.
- Nurses must be vigilant and sensitive to the potential for abuse in the frail and vulnerable adult.
- Nurses must assess subtle signs of abuse.
- Nurses must proceed with a full assessment, including determination of safety of the victim.
- Nurses need to participate in the prevention and early recognition of potential abuse.
(Touhy & Jett, 2016)
Jean is a 25-year-old with muscular dystrophy and moderate intellectual disabilities. She is dependent on her parents for all her activities of daily living and attends a special school to assist her with her disabilities. On a recent field trip with the school, Jean’s teacher left her alone and unsupervised in the school van with two male students for approximately ten minutes. While the teacher was gone, one of the young males removed Jean’s shirt and took a picture of the two of them while he fondled her breasts. Upon arriving back at the school, the two male students showed the picture to other students.
Back at home after school, Jean, distraught from the incident, tearfully told her mother what had happened. Jean’s mother, Barbara, who happens to be a nurse, immediately called the police and then the school administrator. Although Barbara is not considered a mandatory reporter in this instance since she did not learn of the abuse while working in her professional capacity, she is well aware of the harmful effects of the abusive actions of the male students, and she felt that calling the police would be the correct intervention for her to take as a permissive reporter.
The police began an investigation for dependent adult abuse in the form of personal degradation and sexual exploitation. They also directed the complaint to the Iowa Department of Human Services for further assessment, and a social worker began to help Jean and her parents to find another school and to seek psychological/mental health services. An investigation was also begun of the school.
What Is the Required Reporting Process?
IMMEDIATE PROTECTION CONTEXT
If urgent protection is believed necessary for the dependent adult, a reporter should immediately call 911 or law enforcement. The law enforcement personnel receiving this information must then report to the DHS.
Mandatory reporters who suspect abuse of a dependent adult or elder abuse within the community must immediately make an oral report to the Department of Human Services by calling the abuse report line at 800-362-2178. Reporters who are a staff member or employee must also notify the person in charge (IAC 235B.3).
When an oral report is accepted for evaluation and assessment, a written report is required by the mandatory reporter within 48 hours after the oral report. Reporters must complete IA-DHS Form 470-2441, “Suspected Dependent Adult Abuse Report,” or follow a format that meets reporting requirements. The written report must then be submitted either by fax to 515-564-4112 or email to DHSAbuseRegistry@dhs.state.ia.us (IA DHS, 2017c).
(View Iowa DHS Form 470-2441).
HEALTHCARE FACILITY CONTEXT
If abuse occurs in a facility as defined above, the mandatory reporter must immediately notify the person in charge, who must then notify the Department of Inspections and Appeals within 24 hours (IAC 235E.2).
Reports must be made by taking at least one of the following actions:
- Call the DIA complaint intake line at 877-686-0027 or 515-281-7102.
- Submit a complaint online at https://dia-hfd.iowa.gov/DIA_HFD/Home.do. To access the online complaint form, select “Complaints” from the menu. When the page loads, scroll to the bottom of the page and press the “Proceed to Complaint” button.
- Fax a complaint to 515-281-7106 or email to HFD_Complaint@dia.iowa.gov.
- Mail a complaint to Iowa Department of Inspections and Appeals, Health Facilities Division/Complaint Unit, Lucas State Office Building, 321 East 12th Street, Des Moines, IA 50319-0083.
Some victims of dependent adult abuse may be able to self-report if they are provided with an opportunity to do so. Unfortunately, however, the rate of self-reporting abuse is low due to fear, futility, and/or embarrassment. Those who wish to self-report elder abuse may take any of the following actions:
- Call 911 if you are in immediate danger.
- Speak up; if unhappy with your care, tell someone you know and trust; ask that person to report the abuse, neglect, or substandard care to the Elder Locator Helpline, Victim Connect Hotline, or the Office of the State Long-Term Care Ombudsman; or make the call yourself. (See “Resources” at the end of this course for contact information.)
- Report to the Adult Protective Services agency within your Iowa county.
The National Survey on Abuse of People with Disabilities examined disabled dependent adults and the frequency of self-reporting of abuse. Findings indicated:
- Among individuals with disabilities who reported they had been victims of abuse, 37.3% said they had reported it to the authorities.
- Among family members of these victims, the rate of reporting jumped to 51.7%.
- The majority of these victims said they had experienced abuse on more than 20 occasions.
Source: Baladerian et al., 2013.
Iowa Code requires the following information to be reported:
- Names and home addresses of the dependent adult, relatives, caretakers, and other people believed to be responsible for the dependent adult’s care
- The dependent adult’s present whereabouts, if not the same as the address given
- The reason the adult is believed to be dependent
- The dependent adult’s age
- The nature and extent of the adult abuse, including evidence of previous adult abuse
- Information concerning the suspected adult abuse of other dependent adults in the same residence
- Other information that may be helpful in establishing the cause of the abuse or the identity of the person(s) responsible for the abuse or helpful in assisting the dependent adult
- Reporter’s name and address
(IA DHS, 2017a)
BARRIERS TO REPORTING
Researchers estimate that only 1 of every 14 incidents of dependent adult abuse actually come to the attention of law enforcement or human service agencies. Dependent adult abuse is one of the most underrecognized and underreported social problems in the United States. It is far less likely to be reported than child abuse because of the lack of public awareness (NCOA, 2017).
There are significant barriers to reporting the abuse of dependent elders.
Professional barriers may exist among those who hold the following beliefs:
- Reporting abuse will hurt the relationship with the victim.
- If found out, the abuser will retaliate with more abuse on the victim.
- Fear of losing a job or position.
- The reporter will lose work time due to court appearances associated with the case.
- Nothing will change and everyone involved will get upset.
- The reporter has not been able to get DHS or DIA to accept a report before.
- “I don’t want to get involved” or “It’s none of my business.”
- Communication barriers (i.e., language or not following principles of good communication).
Victim barriers may cause an abused adult not to report:
- Lack of confidence
- Feels as if they somehow deserve the abuse
- History of prior abuse
- Fear of retaliation by the abuser
- Fear of abandonment
- Cultural beliefs (e.g., “What happens at home is nobody else’s business.”)
- Vowed to secrecy by the abuser
- Threats from abuser (e.g., that they will send the victim to a nursing home or withhold food and other necessities)
Source: Schmeidel et al., 2012.
Processing Mandatory Reports
Immediately upon receipt of a report of dependent adult abuse, the Iowa Department of Human Services will begin its evaluation process. The protocol includes these steps:
- Intake of written report
- Make an oral report to the Central Abuse Registry (which provides a single source for the statewide collection, maintenance, and dissemination of dependent adult abuse information)
- Documentation of evaluation through completion of reports
- Documentation of conclusions and recommendations for services or court action
- Completion of required correspondence to subjects and mandatory reporters
- Forward a copy of the written report to the Registry
- Notify the local county attorney of the receipt of the report
- Commence an appropriate evaluation or assessment
EVALUATION AND ASSESSMENT
The purpose of the evaluation is the protection of the dependent adult named in the report. The process of evaluating and assessing will include all of the following:
- Identification of the nature, extent, and cause of the adult abuse, if any, to the dependent adult named in the report
- The identification of the perpetrator(s) responsible for the adult abuse
- A determination of whether other dependent adults at the same residence have been subjected to adult abuse
- A critical examination of the residential environment of the dependent adult named in the report and the dependent adult’s relationship with caretakers and other adults in the same residence
- A critical explanation of all other pertinent matters
A copy of the evaluation report, including anticipated actions or those actions that have been taken, will be transmitted to the Central Abuse Registry within 20 regular working days after the DHS received the initial adult abuse report. Upon receipt of the completed report, all subjects and mandatory reporters are notified in writing of the conclusions drawn from the evaluation report.
OUTCOMES OF THE REPORT
In the state of Iowa, the Department of Human Services and the Department of Inspections and Appeals have three possible outcomes in a dependent adult abuse evaluation:
- Founded: It is determined by a preponderance of evidence (more than 50%) that abuse has occurred. Information on founded reports is maintained on the Central Abuse Registry for ten years and then sealed.
- Unfounded: It is determined by a preponderance of evidence (more than 50%) that abuse has not occurred. Information on unfounded reports is destroyed five years from the date they were unfounded.
- Confirmed, not registered: It is determined by a preponderance of evidence (more than 50%) that abuse has occurred. When physical abuse or denial of critical care by a caretaker is determined to be minor, isolated, and unlikely to reoccur, the report is maintained for five years and then destroyed, unless a subsequent report is founded.
When the DHS determines that abuse has occurred, it will act to protect the dependent adult. When there is no way to protect a dependent adult adequately with voluntary services, the district court may be petitioned to intervene on behalf of the dependent adult and may be petitioned to do any of the following:
- Authorize the provision of protective services to a dependent adult suspected of being abused and who lacks the capacity to consent to receipt of such services
- Prohibit by law a caretaker from interfering with the provision of protective services to the victim
- Order the provision of services to the victim who is in immediate threat to health and safety: 1) removal of the dependent adult to safer surroundings; 2) provision of medical services to the dependent adult; and 3) provision of other needed services to the dependent adult
- Restrain a caretaker from abusing the dependent adult
Protective Appointment Interventions
When the DHS determines that the best interests of the dependent adult may require court action, DHS may initiate action for 1) the appointment of a guardian or conservator; or 2) the admission or commitment to an appropriate institution or facility, pursuant to the applicable procedures under Iowa Code. The following appointment interventions may be utilized in these cases (IAC 235B):
- Conservatorship: When one person is appointed by the court to assume responsibility for custody and control of the property of another (victim)
- Guardianship: When one person is appointed by the court to make personal and healthcare decisions for another person (victim) who is incapacitated
- Power of attorney: When one person (the principal) gives to another person (the attorney in fact) the authority to act on the principal’s behalf in one or more matters, including general powers (financial); limited or temporary powers; durable; and healthcare
- Legal orders: Protective, restraining, and injunctive orders intended to protect the victim from further harm and prevent further abuse
- Substance abuse/mental health commitment: When a person—either the perpetrator or the victim (from self-neglect)—is committed to a facility or hospital for care and treatment
- Voluntary services: The provision of social services needed to protect the dependent adult and assist the adult toward independence
Harry Johnson is a 78-year-old retired farmer who has multiple chronic health problems and dementia. He is being considered for discharge from acute hospital care to home after experiencing complications with his diabetes. His caregiver is his wife of 45 years, Betty.
While the registered nurse, Anita, was doing the discharge planning for Harry, she discovered that Betty does not want Harry to return home because his dementia has caused Harry to have violent outrages targeted at her. Betty shared with Anita that at one point Harry had thrown her to the ground, breaking her ankle, and while she was on the ground, he punched her in the head and threatened to kill her. Betty stated she had not called the police or told anyone of Harry’s violent behavior, since he had threatened to kick her out of the house if she said anything. She was now afraid for her own well-being and life.
As a mandatory reporter, Anita promptly reported the incident to the Iowa Department of Human Services and also notified her supervisor and Harry’s doctor of the circumstances. In reviewing the information with Betty, the doctor concluded that Harry would be better off getting assistance with his violent behaviors and other care needs at a facility providing long-term dementia care, where he would receive more supervision. This would also provide Betty with the safety and consolation she needed. While Harry was at the care facility, the DHS would be able to continue with their investigation into the matter.
The doctor and interdisciplinary team made the coordinating arrangements with a facility close to the Johnson’s farm so Betty could conveniently visit Harry. As a result of the DHS evaluation, the court determined that Harry should be committed to the care facility and not be returned to his home.
Urgent Interventions: Community Context
When DHS determines that a dependent adult is suffering from abuse that represents an immediate danger to health or safety of the victim and may represent irreparable harm, then the courts will be petitioned to order any of the following:
- Remove the dependent adult to safer surroundings
- Order the provision of medical services
- Order the provision of available services, including emergency services
- Terminate a guardianship or conservatorship
RIGHT TO SELF DETERMINATION
All adults have a right to self-determination. This means that the dependent adult can refuse services unless a court determines that the person is not competent to make decisions or is threatening his or her own life or that of others (EAPU, n.d.).
Urgent Interventions: Facility or Program Context
If a law enforcement officer has reason to believe that dependent adult abuse, which is criminal in nature, has occurred in a facility or program, the officer will use all reasonable means to prevent further dependent adult abuse, including, but not limited to, any of the following (IAC 235B):
- Remain on the scene as long as there is danger to the dependent adult
- Assist in obtaining medical treatment for the dependent adult
- Provide a dependent adult with immediate and adequate notice of the dependent adult’s rights and understanding:
- “You have the right to ask the court for the following help on a temporary basis:
- “Keeping the alleged perpetrator away from you, your home, your facility, and your place of work
- “The right to stay at your home or facility without interference from the alleged perpetrator; and
- “Professional counseling for you, your family, or household members, and the alleged perpetrator of the dependent adult abuse
- “If you are in need of medical treatment, you have the right to request that the law enforcement officer present assist you in obtaining transportation to the nearest hospital or otherwise assist you.
- “If you believe that police protection is needed for your physical safety, you have the right to request that the law enforcement officer present remain at the scene until you and other affected parties can leave or safety is otherwise ensured.”
- “You have the right to ask the court for the following help on a temporary basis:
LEGAL ISSUES FOR IOWA MANDATORY REPORTERS
Immunity from Liability
An individual participating in good faith by reporting, cooperating, or assisting the department in evaluating a case of dependent adult abuse or participating in a judicial proceeding has immunity from liability, civil or criminal, which may have occurred due to the act of making the report or offering assistance. It is unlawful in the state of Iowa for a person or employer to discharge, suspend, or discipline an individual required to report or voluntarily reporting suspected dependent adult abuse. A person or employer found in violation of this law is guilty of a simple misdemeanor (IAC 235B).
Rights and Sanctions
A mandatory reporter required to report a suspected case of dependent adult abuse who knowingly and willfully fails to do so commits a simple misdemeanor. A mandatory reporter who knowingly interferes with the making of a dependent adult abuse report or applies a requirement that results in failure to make a report is civilly liable for the damages proximately caused by this failure (IAC 235B).
PREVENTION INTERVENTION AND PROGRAMS
Since so few incidents of abuse against dependent adults are ever reported, preventing dependent older abuse in the first place is particularly important. Appropriate prevention interventions must include legislation, education, respite, social support, perpetrator interventions, and money management programs (Daly, 2011).
- Legislation. Statistics have shown that states requiring public education regarding dependent adult abuse correlate with higher abuse report rates, suggesting that heightened public awareness increases reporting of the abuse. Also, states that require mandatory reporting had a significantly higher investigation rate.
- Education. Iowa is the only state that requires education for mandatory reporters, and other states can be encouraged to do the same. Educating older adults, professionals, caregivers, and the public on abuse is critical to prevention.
- Respite. There are three types of respite interventions to prevent dependent adult abuse: adult day care respite, in-home respite, and institutional respite. These programs can help reduce the stress and strain placed on those caring for dependent adults.
- Social Support. Individual psychosocial interventions for long-term caretakers have been found helpful in alleviating caretaker stress.
- Perpetrator Interventions. Programs with this focus include assisting the perpetrator to confront their attitudes about control, learn anger-management skills, engage in cognitive therapy, or a combination of these.
- Money Management Programs. In order to prevent financial exploitation, these programs have been tried, with marginal success. If dementia or other cognitive issues are involved, medical intervention is suggested.
The Iowa Department on Aging (DoA) administers the Elder Abuse Prevention and Awareness Program to address the problem of dependent adult abuse, neglect, and exploitation. Educating older adults, professionals, caregivers, and the public on elder abuse is critical to prevention. This program provides and develops education programs and policies that can assist in the prevention of elder abuse in Iowa (IA DoA, 2017a).
In order to meet its prevention goal, the DoA distributes funds to Area Agencies on Aging in order to:
- Employ elder rights specialists
- Counsel families who are concerned about the safety or well-being of a loved one
- Develop personalized intervention plans to reduce identified risks
- Provide information about and referrals to appropriate protective service agencies.
Iowa produces a “Plan on Aging” on a three-year basis, with the FY 2018–2021 plan incorporating promoting healthy lifestyles, aging in place, abuse prevention of dependent adult Iowans, and protecting and preserving their rights (IA DoA, 2017b).
PREVENTATIVE ACTIONS FOR OLDER ADULTS
Recommendations for Iowa’s older adults to help them stay safe include:
- Take care of your health.
- Seek professional help for drug, alcohol, and depression concerns and urge family members to get help for these problems.
- Attend support groups for spouses and learn about domestic violence services.
- Plan for your own future. With a power of attorney or a living will, you can address healthcare decisions now to avoid confusion and family problems later. Seek independent advice from someone you trust before signing any documents.
- Stay active in the community and connected with friends and family. This will decrease social isolation, which has been connected to elder abuse.
- Post and open your own mail.
- Do not give personal information over the phone.
- Use direct deposit for all checks.
- Have your own phone.
- Review your will periodically.
- Know your rights. If you utilize the services of a paid or family caregiver, you have the right to voice your preferences and concerns.
The Office of the State Long-Term Care Ombudsman advocates for residents and tenants of long-term care facilities, including nursing facilities, residential care facilities, assisted living programs, and elder group homes. The ombudsman seeks to resolve complaints that impact the health, safety, and welfare of residents and tenants, as well as by informing residents and tenants of their rights.
Source: IA DOJ, 2017.
As the largest healthcare profession, nursing has an ethical, moral, and legal responsibility to understand and address the complexities of dependent adult abuse. Community service agencies, care facilities, clinics, and other healthcare centers are ideal places to embed the frameworks presented here for assessing and identifying dependent adults who are at risk for abuse.
Nurses and other professionals serve as advocates for all those in their care, including the most vulnerable. It is through education and interdisciplinary teamwork that mandatory reporters can provide a compassionate and quick response to suspected abuse in order to protect the safety and well-being of the dependent adults within our communities and facilities.
Abuse Hotline (to report dependent adult abuse in the community)
Elder Locator Helpline (to self-report abuse)
Health Facilities Division Complaint Unit (to report dependent adult abuse in a facility)
Iowa Sexual Abuse Hotline
Iowa Victim Service Call Center (to report domestic violence)
Victim Connect Hotline (to self-report abuse)
Abuse Coordinating Unit (IA Department of Inspections & Appeals)
Dependent Adult Abuse Program (IA Department of Human Services)
Form 470-2441: Suspected Dependent Adult Abuse Report (IA Department of Human Services)
Office of the State Long-Term Care Ombudsman (IA Department on Aging)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.
Acierno R, Hernandez M, Amstadter A, Resnick H, Steve K, Muzzy W, & Kilpatrick D. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292–7. Doi:10.2105/AJPH.2009.163089
Administration on Aging (AoA). (2016). Profile of older Americans: 2015. Retrieved from https://www.acl.gov
American Society on Aging (ASA). (2016). Social media abuse in long-term care is just the tip of the iceberg. Retrieved from http://www.asaging.org
Amstadter A, Cisler J, McCauley J, Hernandez M, Muzzy W, & Acierno R. (2011). Do incident and perpetrator characteristics of elder mistreatment differ by gender of the victim? Results from the National Elder Mistreatment Study. Journal of Elder Abuse and Neglect, 23(1), 43–57. Doi:10.1080/08946566.2011.534707
Baladerian N, Coleman T, & Stream J. (2013). Abuse of people with disabilities: victims and their families speak out. Los Angeles: Spectrum Institute. Retrieved from http://disability-abuse.com
Boltz M, Capezuti E, Fulmer T, & Zwicker D. (2016). Evidence-based geriatric nursing protocols for best practices (5th ed.). New York: Springer Publishing Co.
Burston G. (1975). Letter: granny-battering. British Medical Journal, 3, 592. Retrieved from https://www.ncbi.nlm.nih.gov
Connolly M, Brandl B, & Breckman R. (2014). The elder justice roadmap: a stakeholder initiative to respond to an emerging health, justice, financial, and social crisis. National Center on Elder Abuse. Retrieved from https://vawnet.org
Daly J. (2011). Evidence-based practice guideline: elder abuse prevention. Journal of Gerontological Nursing, 37(11), 11–7.
Elder Abuse Prevention Unit (EAPU). (n.d.). Rights of older people. Retrieved from http://www.eapu.com.au
End Abuse Late in Life (EALL). (2017). Dynamics of abuse later in life. Retrieved from https://www.eallsav.org
Hoover R & Polson M. (2014). Detecting elder abuse and neglect: assessment and intervention. American Family Physician, 89(6), 453–60. Retrieved from http://www.aafp.org
Iowa Administrative Code (IAC). (2016a). Chapter 235B: dependent adult abuse services—information registry. Retrieved from https://www.legis.iowa.gov
Iowa Administrative Code (IAC). (2016b). Chapter 235E: dependent adult abuse in facilities and programs. Retrieved from https://www.legis.iowa.gov
Iowa Administrative Code (IAC). (2015). Chapter 235F: elder abuse. Retrieved from https://www.legis.iowa.gov
Iowa Board of Nursing. (2015). Newsletter, 34(1), 1–2. Retrieved from http://publications.iowa.gov
Iowa Department of Human Services (IA DHS). (2017a). Dependent adult abuse. Retrieved from http://dhs.iowa.gov
Iowa Department of Human Services (IA DHS). (2017b). Dependent adult abuse statistical report. Retrieved from http://dhs.iowa.gov
Iowa Department of Human Services (IA DHS). (2017c). Department of Human Services forms. Retrieved from http://dhs.iowa.gov
Iowa Department of Human Services (IA DHS). (2012). Dependent adult abuse intake. Retrieved from https://dhs.iowa.gov
Iowa Department of Inspections & Appeals (IA DIA). (2017a). Governor signs house file 544 into law. Retrieved from https://dia.iowa.gov
Iowa Department of Inspections & Appeals (IA DIA). (2017b). Health facilities division: complaints. Retrieved from https://dia-hfd.iowa.gov
Iowa Department of Justice (IA DOJ). (2017). Preventing elder abuse. Retrieved from https://www.iowaattorneygeneral.gov
Iowa Department on Aging (IA DoA) (2017a). Elder abuse prevention & awareness. Retrieved from https://www.iowaaging.gov
Iowa Department on Aging (IA DoA) (2017b). Iowa state plan on aging: federal fiscal years 2018–2021. Retrieved from https://www.iowaaging.gov
Jett K. (2014). Economic and legal issues. In Ebersole & Hess, Gerontological nursing & healthy living, pp. 361–74, St. Louis: Elsevier and Mosby.
Legal Information Institute (LII). (2008). U.S. Code, title 42, chapter 26, 12102—definition of disability. Retrieved from https://www.law.cornell.edu
National Center on Elder Abuse (NCEA). (2012). Abuse of residents of long-term care facilities. Retrieved from http://www.ncea.aoa.gov
National Center on Elder Abuse (NCEA). (n.d.). Research. Retrieved from https://ncea.acl.gov
National Council on Aging (NCOA). (2017). Elder abuse facts. Retrieved from https://www.ncoa.org
Salsbury SA. (2011). Clinical brief: recognizing, reporting and responding to dependent adult abuse. Integrative Health: International Journal, 2(3), 1–5. Retrieved from http://www.tihcij.com
Schmeidel A, Daly J, Rosenbaum M, Schmuch G, & Jogerst G. (2012). Healthcare professionals’ perspectives on barriers to elder abuse detection and reporting in primary care settings. Journal of Elder Abuse and Neglect, 24(1), 17–36. Retrieved from https://www.ncbi.nlm.nih.gov
Touhy T & Jett K. (2016). Common legal and ethical issues. Ch. 31 in Ebersole & Hess, Toward healthy aging: human needs and nursing response. St. Louis: Elsevier.